Anesthesiology and Pain Medicine
Volume:6 Issue: 3, Jun 2016

Context: Caffeine is the most commonly used psychoactive legal drug in the world. Caffeine’s role in controlling pain has received less attention in the past, yet is being increasingly considered. This article briefly reviewed the literature to clarify the role of caffeine as a drug for pain control and attract investigators to this topic..
Evidence Acquisition: The data on Caffeine as an adjuvant therapy or as a main component for pain modulation has been narratively reviewed..
Caffeine plays an important role in pain modulation through their action on adenosine receptors which are involved in nociception. The use of caffeine as adjuvant treatment was well-established in the literature and caffeine is currently available in some over the counter medications. Studies showed controversial results about the interaction between caffeine and morphine for pain relief in patients with terminal stage cancer. As a main component for pain modulation, Caffeine can be used for hypnic headache and postdural puncture headache..
Caffeine has a potential role for pain modulation. Current evidence on caffeine use for migraine and terminal stage cancer is not well-established. Future studies should address the use of caffeine alone for different types of pain with dose escalation and standardization of outcome measurement..

Intravenous Regional Anesthesia (IVRA) is a well-known technique for producing analgesia during surgical procedures in the extremities. However, the rapid onset of pain following the deflation of a double-cuff tourniquet during IVRA is a serious disadvantage, leading patient suffering..
The aim of this study was to evaluate the clinical effectiveness of a pneumatic arm tourniquet applied 2 cm above the double-cuff tourniquet in controlling the pain that occurs after its deflation..
Patients and Twenty patients undergoing outpatient hand surgery were operated on under IVRA, using 40 - 50 mL of a solution containing 3 mg/kg of lignocaine. A simple pneumatic tourniquet was applied proximal to the double-cuff tourniquet, 3 min before its deflation, while the procedure was being conducted. The severity of pain on the basis of the Numerical Rating Scale (NRS) was assessed throughout the operation, and continued until an hour after the double-cuff tourniquet was removed..
The mean operation time after the deflation of the double-cuff tourniquet was 20.12 ± 6.1 minutes. Moreover, the mean NRS for the post-deflation time was insignificant (NRS = 2), and only one patient during first 20 minutes received opioids..
This study showed that a pneumatic arm tourniquet as an adjunct to IVRA provides acceptable analgesia following the deflation of the double- cuff tourniquet for relieving surgical pain..

Underdevelopment of the lung parenchyma associated with abnormal growth of pulmonary vasculature in neonates with congenital diaphragmatic hernia results in pulmonary hypertension which mandates smooth elective mechanical ventilation in postoperative period, for proper alveolar recruitment and oxygenation, allowing lungs to mature enough for its functional anatomy and physiology. Dexmedetomidine is sympatholytic, reduces pulmonary vascular resistance and exerts sedative and analgesic property to achieve stable hemodynamics during elective ventilation. Neonatal experience with dexmedetomidine has been predominately in the form of short term or procedural use as a sedative..
The preliminary clinical experience with pre-induction to 48 hours postoperative use of dexmedetomidine infusion as a pharmacologic adjunct in the emergency corrective surgery of three such neonates are presented..
Hemodynamics remained virtually stable during the whole procedure and post-operative pain relief and recovery profile were satisfactory. The prolonged infusion was well tolerated with a gradual trend towards improved oxygen saturation. Careful planning of the anesthetic management and the ability to titrate the adjunct utilized for smooth postoperative ventilation are the keys to ameliorate the complications encountered and favorable outcomes achieved in such patients..

Intrathecal baclofen pumps are valuable treatment options for those with cerebral palsy. Although subfascial baclofen pump placement is generally preferred over a subcutaneous pump placement due to lower infection rates, rare complications can occur with the subfascial approach such as pump migration..
The authors here describe a case of baclofen pump migration into the peritoneal cavity of a 26-year-old male patient with cerebral palsy, shunted hydrocephalus, and epilepsy. Because the patient’s pump could not be palpated on exam and hence refilled, imaging was undertaken, but did not reveal clear evidence of pump migration. Surgery afterward confirmed that the pump had migrated into the peritoneal cavity through a fascial defect. Baclofen pump had to be replaced instead subcutaneously as well as the patient later had to be readmitted for 2 ventriculoperitoneal shunt revisions due to progression of his hydrocephalus..
Intraperitoneal migration of a subfascially placed baclofen pump is a rare, yet serious complication, which has been reported only once in the literature. We advise neurosurgeons to have a low level of threshold in confirming the location of a baclofen pump with imaging and surgical exploration if necessary in order to avoid detrimental outcomes such as bowel perforation..

Context: Pre-existing renal dysfunction presents specific features that anesthesiologists must deal with. Anesthesia and renal function are connected and can interfere with each other. Induced hypotension anesthesia and the toxic effects of anesthetic drugs can further deteriorate renal function..
Evidence Acquisition: Decreased renal function can prolong anesthetic drug effects by decreased elimination of these drugs. Anesthesia can deteriorate renal function and decreased renal function can interfere with drug elimination leading to their prolonged effect. The anesthesiologist must understand all the physiological aspects of the patient, renal protection, and the relationships between anesthetic drugs and renal function. This review article aims to summarize these aspects..
Perioperative renal failure and renal protection is a crucial moment in clinical practice of every anesthesiologist..
Good knowledges for renal function remain a hallmark of daily practice of the anesthesiologist, considering renal function as an important determinant factor in anesthesia practice..

Pregabalin, a structural analogue of gamma amino butyric acid (GABA), is shown to be effective in treatment of several types of neuropathic pain, incisional injury, and inflammatory injury..
The aim of the present study is to compare the efficacy of two doses (75 mg or 150 mg) of pregabalin with the administration of a placebo for post-operative analgesia in patients undergoing hysterectomy under spinal anesthesia..
Patients and A randomized, placebo-controlled trial was conducted on 135 patients undergoing vaginal hysterectomy under spinal anesthesia. The patients were divided in three groups of 45 patients each: group 0, placebo; group 1, 75 mg pregabalin; and group 2, 150 mg pregabalin; each treatment of which was administered one hour before surgery. The Ramsay sedation scale (RSS) was used for pre-operative assessment and the visual analog scale (VAS) was used to determine pain at rest and for cough on the first post-operative day. The time for the requirement of rescue analgesics on the first post-operative day was also assessed..
The RSS scores were significantly higher in groups 1 and 2 as compared to the controls (P Pregabalin administered as premedication provided significant postoperative pain relief and decreased the requirement of other parenteral analgesics. Pregabalin doses of 150 mg had a better analgesic profile, but the advantages of their use may be limited by side effects such as dizziness. Thus, it is concluded that pregabalin doses of 75 mg may be the optimal pre-emptive dose..

Preemptive analgesia is the blocking of pain perception afferent pathways before noxious painful stimuli. Clonidine is an alpha agonist drug that is partially selective for α-2 adrenoreceptors. Clonidine is used as anti-anxiety medication and an, analgesic, and it prolongs the duration of the block in the brachial plexus block..
To compare the effect of preemptive clonidine with midazolam on intraoperative sedation, duration of block, and postoperative pain scores..
Patients and In a randomized clinical trial, 80 patients with orthopedic fractures of an upper extremity who underwent supraclavicular nerve block were randomly assigned to receive 0.2 mg oral clonidine or 2 mg oral midazolam. Intraoperative sedation was measured at one hour after the start of urgery and again in the PACU (Post-Anesthesia Care Unit) using the Ramsay scale. The duration of sensory blockade was measured. Postoperative pain scores were measured using the VAS (Visual Analogue Scale) after entrance to recovery up to 2 hours..
The percentages of patients in the calm and sedated scale were significantly higher in clonidine group (35 and 42.5%, respectively), compared to the midazolam group (17.5 and 17.5%, respectively) (P = 0.042, 0.029; respectively). Those administered fentanyl in the clonidine group 105 ± 30.8 was significantly lower than that for the midazolam group 165 ± 34.5 (P = 0.0018). The percentages of patients in the calm scale were significantly higher in the clonidine group (52.5), compared to the midazolam group (17.5) (P = 0.001) in the post-operative period. VAS scores were significantly lower at one (P = 0.01) and two hours (P = 0.001) after operation in the clonidine group, compared to the midazolam group..
Preemptive clonidine has many marvelous advantages over midazolam, including better sedation inside the operating room and then in the post-operative care unit, lower fentanyl doses are required during surgery, more stable heart rate and blood pressure are observed during the procedure, and patients report lower post-operative pain scores..

Electroconvulsive therapy (ECT) is a safe and effective mode of therapy for a wide variety of psychiatric disorders. However, it is associated with some disturbing side effects, such as nausea and vomiting, dental and tongue injury, confusion, dizziness, headache, and myalgia..
The present study focused on the evaluation of myalgia and headache and their predictors after ECT..
Patients and A prospective analytical descriptive study was conducted from October 2014 to January 2015, in an academic hospital in northern Iran. Before sampling, the study was approved by the ethics committee of Guilan University of Medical Sciences. 621 patients with psychiatric disorders who were referred to Shafa hospital enrolled in the study. They were evaluated based on a verbal rating scale (4 point scales) 6 hours after ECT, regarding headache and myalgia side effects..
6 hours after ECT, 126 patients (21.9%) reported headaches, and 56 patients (9%) reported myalgia. The presence of headache or myalgia 6 hours after ECT was not correlated to the duration of convulsion, treatment sessions, sex, or age. But myalgia at 2 hours after treatment was correlated with sex (0.04). Sex, age, duration of seizure, and treatment sessions were not predictors of headache and myalgia 6 hours after ECT (log regression, enter mode). The intensity and frequency of headaches decreased during 6 hours after ECT (P = 0.0001 and P = 0.0001, respectively), and myalgia frequency decreased (P = 0.062) but the intensity increased (P = 0.87)..
The results of the present study demonstrate that headache after ECT procedures was more common than myalgia, but it was mild, tolerable, and decreased within 6 hours of the treatment. It is also notable that we did not found any predictors for post-ECT headache and myalgia..

Postoperative shivering is a major problem in children undergoing general anesthesia..
The aim of the present study was to investigate the role of low-dose intravenous ketamine for prevention of shivering after induction of general anesthesia in children who had undergone tonsillectomy..
Patients and This was a randomized, double-blinded, placebo-controlled trial including 80 children, of American society of anesthesiologists (ASA) physical status I or II, scheduled for tonsillectomy under general anesthesia who were randomly assigned to an intravenous ketamine (0.5 mg/kg, n = 40; group K) group or matched dose placebo (n = 40; group N) group. Surgical and demographic data, unexpected side effects, and the occurrence of shivering for each child were assessed by a blinded observer at the following time points: T0, in the recovery room; T10, at 10 minutes; T20, at 20 minutes; T30, and at 30 minutes..
With regards to the demographic and surgical data, no significant differences between the two study groups were observed (P ≥ 0.05). Shivering intensity in children who had received ketamine was significantly lower than children who had not received ketamine, at T0, T10, T20, and T30 after arrival (P Administration of intravenous ketamine at a dosage of 0.5 mg/kg immediately after anesthesia induction had a preventive effect on shivering intensity without hemodynamic alterations in children undergoing general anesthesia for tonsillectomy..

Pulmonary collapse after intubation is common, and it is caused by a variety of factors..
A 21-year-old man presented at our operation room to undergo an appendectomy. Except for a history of cigarette smoking, his history was negative. Anesthesia was induced with 100% oxygen and sevoflurane, remifentanil infusion, and propofol. Neuromuscular block was obtained with rocuronium. The tip and cuff of a tracheal tube were lubricated with a topical metered-dose of 8% Lidocaine pump spray. After intubation, SPO2 suddenly decreased. The chest x-ray revealed right upper lobe atelectasis. Fiber optic bronchoscopy showed that a large amount of yellow sticky mucus had been secreted into the right main bronchus..
In Japan, 8% Lidocaine pump spray contains menthol and ethanol as additives. These additives, particularly menthol, might have led to excessive mucus production, although we did not analyze the mucus secretion..

Context: Migraine and cluster headache are undoubtedly painful conditions. The respective pathogenesis of these two conditions is incompletely understood. In both cases, the treatments used have largely been empirical and have relied to a much lesser extent on our understanding of the mechanisms causing pain. We hereby review the pain mechanisms in migraine and cluster headache, two of the commonest primary headache disorders..
Evidence Acquisition: A review of the English literature was conducted by searching PubMed for studies on pain mechanism in migraine and cluster headache. We entered [migraine] and [pain mechanism] in Pubmed and 488 articles were obtained. Articles were then included according to their relevance to the topic. Similarly, [cluster headache] and [pain mechanism] revealed 79 search results..
There is evidence that the trigeminovascular system and neurogenic inflammation play important roles, together with certain areas of the brain, leading to these conditions being termed ‘neurovascular headaches’. Functional imaging findings suggest a possible role of the dorsolateral pons in generating migraine attacks while the role of the hypothalamus in cluster headache is more firmly established..
Migraine and cluster headache have complex pathophysiologies. The exact mechanism causing pain in both conditions is incompletely understood and more research needs to be undertaken in this area..

Postoperative pain from open reduction and internal fixation of mandibular fracture is a serious issue. Amantadine is an N-methyl-D-aspartic acid or N-methyl-D-aspartate (NMDA) receptor antagonist that can be effective against postoperative pain..
The present study examined the efficacy of amantadine in alleviating the postoperative pain of mandibular fracture surgery..
Patients and In this double-blind study, 60 patients (ASA physical status I–II) were randomly divided into two groups. The mean ages of the participants were 31.2 ± 13.1 years and 32.3 ± 18.1 years, respectively. The male/female ratios were 24/6 and 26/4, respectively, in the case and control groups. Randomization was based on a single sequence of random assignments using computer-generated random numbers. Group I was given oral amantadine 100 mg 1 hour before surgery, and group II received a placebo at the identical time. Through PCA pumps, patients received a bolus dose of morphine at 0.02 mg/kg body weight, to a maximum of 1.5 mg. PCA pumps were set at 6 minutes lockout intervals and a maximum dose of 0.15 mg/kg/h, to a maximum of 10 mg/h. Pain was assessed using a visual analog scale (VAS) at 0, 2, 4, 6, 12, and 24 hours and 1, 2, 3, 4, 5, and 6 months after surgery. The amounts of analgesic consumed were recorded for the first 24 hours, and for 6 months after surgery..
There were no significant differences between the two groups with respect to age, gender, nausea and vomiting, sleep quality, blood pressure, and heart rate. No significant differences were observed between the two groups in pain scores (P = 0.39) and analgesic consumption (P = 0.78)..
The results suggest that a single dose of preoperative oral amantadine did not reduce acute or chronic postoperative pain, nor analgesic consumption..

Tracheal intubation is an essential method of keeping the airway open in patients under general anesthesia. Sore throat is a prevalent complication after endotracheal intubation..
The aim of this study was to investigate the effect of green tea gargling on sore throat after coronary artery bypass grafting (CABG)..
Patients and This was a single-blind, randomized clinical trial, in which 121 patients who had undergone CABG were divided into two groups: those who gargled distilled water and those who gargled a green tea solution. An hour after extubation, the patients of the intervention group were asked to gargle 30 cc of green tea, and the patients of the control group were asked to gargle 30 cc of distilled water, every 6 hours for up to 24 hours (four times per patient). A sore throat questionnaire was filled out 6, 12, and 24 hours after endotracheal extubation..
The results showed that there were no significant differences between the two groups with regard to patient age, sex, body mass index, smoking background, and duration of anesthesia. There was no significant difference between the two groups in terms of sore throat before the intervention (P = 0.461) and 6 hours after the intervention (P = 0.901). However, a significant difference was observed between the two groups in terms of sore throat 12 hours (P = 0.047) and 24 hours (P Gargling a green tea solution, an anti-inflammatory, natural, and harmless substance, can reduce the pain of sore throat in patients after endotracheal extubation..

Several factors are thought to affect the spread and duration of spinal anesthesia (SA) in adults. These include the volume of cerebrospinal fluid (CSF) in the lumbar spinal canal, which has a negative correlation with both the spread and duration of the sensory block..
We evaluated whether CSF aspiration before an injection of levobupivacaine affected the spread or duration of SA in children..
Patients and SA was induced by levobupivacaine (5 mg/mL, 0.25 - 0.5 mg/kg) in 186 children aged 10 months to 18 years (mean of 7.5 years). Two groups were analyzed prospectively: 93 children from which 1 - 3 mL of CSF (CSF-aspiration group) was aspirated before the injection of levobupivacaine to induce SA and 93 children from which no CSF was aspirated (no-CSF-aspiration group) prior to the injection of levobupivacaine. The main outcome measure was regression of the sensory block below T10, cephalic spread of the block, and postpuncture complications after SA..
There were no between-group differences in the time to regression of the block below T10 or in the cephalic spread of the sensory block: 94 (27) minutes and T4.4 (SD 2.2) in the CSF-aspiration group, respectively, vs. 97 (29) minutes and T4.3 (1.8), respectively, in the no-CSF-aspiration group. Position-dependent headaches developed in 4 of 91 children in the CSF-aspiration group and 5 of 86 children in the no-CSF-aspiration group, but no epidural blood patches were required..
The aspiration of 1 - 3 mL of CSF before an injection of levobupivacaine did not seem to affect the spread and duration of the sensory block or postpuncture complications in children following SA..

Dexmedetomidine is a potent and highly specific α2-adrenoreceptor agonist that induces sedative and analgesic effects over a short-term period. As a result of these benefits, dexmedetomidine may be a better alternative than other available drugs for keeping the patient’s cognition state in an acceptable condition after outpatient ophthalmic surgeries..
This randomized study was conducted to compare the sedative effects of dexmedetomidine and remifentanil on the cognitive state of patients who have undergone cataract surgery..
Patients and A total of 100 patients who were candidates for cataract surgery under local anesthesia received either dexmedetomidine (50 patients; D group) or remifentanil (50 patients; R group) in a double-blind, randomized study. The baseline cardiovascular status and mini mental state examination (MMSE) score for each patient were recorded. As a loading dose, dexmedetomidine (0.5 µg/kg) and remifentanil (0.1 µg/kg) were infused at 10 minutes and 5 minutes before topical anesthesia, respectively. Subsequently, the maintenance dose was administered at 0.2 µg/kg/hour and 0.05 µg/kg/minutes in the D and R groups, respectively. The surgical procedure was begun when the bispectral index (BIS) reached 70 - 80. MMSE test was done at a postanesthetic care unit (PACU) 120 minutes after the discontinuation of the drug..
There was no statistically significant difference between the MMSE scores of the two groups before surgery (P = 0.6), but the MMSE test conducted at the PACU revealed significantly better cognitive outcomes in the D group than in the R group in patients younger and older than 65 years (P = 0.03 and P = 0.0001, respectively)..
This study revealed that dexmedetomidine may be a suitable agent for sedation in cataract surgery because it results in a more favorable postoperative cognitive status than remifentanil. Likewise, dexmedetomidine had no significant adverse effects on cardiovascular or respiratory systems..

Anecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection..
Assess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach..
Patients and Participants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography..
First needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed..
This compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring..

The authors evaluated the effectiveness of percutaneous epidural adhesiolysis (PEA) in patients with low back pain due to contained disc herniation..
Patients and Twenty patients with low back pain due to contained disc herniation underwent PEA treatment with the Racz technique. The patients were evaluated for pain score, medication intake, significant pain relief, and complications..
At three days, one month, three months, and six months after PEA compared to pre-PEA evaluations, the pain scores and medication intake were significantly decreased. Significant pain relief declined from 95% at three days to 75% at six months..
PEA for low back pain due to contained disc herniation is a safe and effective procedure. Therefore, it may be considered as an option for treatment before invasive operations are performed..

Central venous cannulation is a current and important procedure used in the operating room and intensive care unit. Some studies have shown that the application of ultrasound-guided cannulation can improve the success rate of surgery, save time, reduce the number of required needlesticks, and mitigate many complications compared to anatomical landmark-guided cannulation..
The aim of the present study was to draw a comparison between central venous cannulation of the internal jugular vein using ultrasound-guided and anatomical landmark-guided techniques..
Patients and A total of 321 patients scheduled for cardiac surgery in the surgical ward of a general hospital were randomly treated with central venous cannulation using either anatomical landmarks (150 patients) or ultrasound guidance (170 patients). The demographic data of patients, the success rate of cannulation, the execution time, and the number of attempts for successful cannulation as well as the complications were recorded and subjected to statistical analysis..
The success rate of cannulation was 98.7% in the anatomical landmark-guided group and 99.4% in the ultrasound-guided group. The average operation times were 46.05 and 45.46 seconds in the anatomical landmark and ultrasound-guided groups, respectively. The two groups were not significantly different in terms of the success rates of treatment, the number of attempts, the time required for successful cannulation, or the prevalence of complications (P > 0.05) other than carotid artery puncture (P = 0.04).
In our conditions, the use of an anatomical landmark-guided procedure was the preferred treatment method due to limited resources and a lack of adequate training..