Anesthesiology and Pain Medicine
Volume:5 Issue: 6, Dec 2015

The brachial plexus block is a commonly performed procedure in the anesthetic practice today. It is performed for analgesia as well as anesthesia for upper limb procedures. It has been used for amputation and replantation surgeries of the upper limb.. We present the case of a 68-year-old gentleman who had brachial plexus block at supraclavicular and interscalene levels as the sole anesthetic for undergoing above elbow amputation. He was deemed to be very high risk for a general anesthetic as he suffered from severe chronic obstructive pulmonary disease (COPD) and a very poor exercise tolerance (NYHA Class III). The supraclavicular brachial plexus block was supplemented with an interscalene brachial plexus block due to inadequate surgical anesthesia encountered with the former. The procedure was successfully completed under regional anesthesia.. The brachial plexus block can be performed at different levels in the same patient to achieve desired results, while employing sound anatomical knowledge and adhering to the maximum safe dose limit of the local anesthetic..

New research shows shown that erythropoietin has neuro-protective effects. In preclinical trial and human clinical trials, it was demonstrated that erythropoietin is effective treatment for spinal cord injury. Early administration of medications after injury increases the hope of attenuating secondary damage and maximizing an improved outcome.. A 42-year-old female patient presented with gait instability and progressive weakness in her right leg over a 6-year period. She was diagnosed as myelomalacia and was candidate for cervical discectomy. After surgery, she suffered from right hemiplegia due to spinal cord injury that did not respond well to routine treatment. Darbepoetin alpha (Aranesp) 100 mcg, subcutaneous daily for three days, was added to the patient’s treatment seven days after trauma and resulted in rapid improvement. The patient recovered progressively and was discharged from the hospital ten days after erythropoietin therapy.. This case report supports the beneficial role of erythropoietin in function, maintenance, and recovery of neurons. Erythropoietin is a double-edge sword, as long-term erythropoietin therapy has some complications, like thromboembolism and stroke. Recent studies suggested that erythropoietin should be given as single high dose to exert a rapid neuro-protective effect with minimal hematopoietic side effects. We believe that the effects and other adverse consequences of erythropoietin and its non-erythropoietic derivatives should be evaluated in clinical trials..

Usually presenting in infancy, Leigh’s syndrome is an inherited condition often manifesting with seizures, ataxia, developmental delay, and dysarthria. The disorder is rare, appearing in approximately 1 in 40,000 live births. Consequently, providing these patients with a suitable plan by which to administer anesthetics remains problematic.. We report a male patient with Leigh’s syndrome and a family history suggestive of unknown hypotonia and malignant hyperthermia presenting for dental rehabilitation.. Dexmedetomidine with remifentanil can be used with no complication in this senerio..

Continuous interscalene blocks provide excellent analgesia after shoulder surgery. Although the safety of the ultrasound-guided in-plane approach has been touted, technical and patient factors can limit this approach. We developed a caudad-to-cephalad out-of-plane approach and hypothesized that it would decrease pain ratings due to better catheter alignment with the brachial plexus compared to the in-plane technique in a randomized, controlled study.. To compare an out-of-plane interscalene catheter technique to the in-plane technique in a randomized clinical trial..Patients and Eighty-four patients undergoing open shoulder surgery were randomized to either the in-plane or out-of-plane ultrasound-guided continuous interscalene technique. The primary outcome was VAS pain rating at 24 hours. Secondary outcomes included pain ratings in the recovery room and at 48 hours, morphine consumption, the incidence of catheter dislodgments, procedure time, and block difficulty. Procedural data and all pain ratings were collected by blinded observers.. There were no differences in the primary outcome of median VAS pain rating at 24 hours between the out-of-plane and in-plane groups (1.50; IQR, [0 - 4.38] vs. 1.25; IQR, [0 - 3.75]; P = 0.57). There were also no differences, respectively, between out-of-plane and in-plane median PACU pain ratings (1.0; IQR, [0 - 3.5] vs. 0.25; IQR, [0 - 2.5]; P = 0.08) and median 48-hour pain ratings (1.25; IQR, [1.25 - 2.63] vs. 0.50; IQR, [0 - 1.88]; P = 0.30). There were no differences in any other secondary endpoint.. Our out-of-plane technique did not provide superior analgesia to the in-plane technique. It did not increase the number of complications. Our technique is an acceptable alternative in situations where the in-plane technique is difficult to perform..

Muscle rigidity and generalized spasm can cause severe pain in patients with tetanus. Administration of high dose sedative or narcotic agents can increase respiratory failure and prolong mechanical ventilation support.. In this report, ultrasound-guided sciatic nerve block was performed in a 25-year-old patient with tetanus to progress his respiratory drive which was decreased due to high dose sedative administration. This procedure accelerates the weaning process and extubation.. Nerve blocks may be appropriate for the particular patient with tetanus to tolerate the pain, reduce depth of sedation, accelerate extubation and subsequently decrease complications of tetanus relating to long time intubation..

The use of laparoscopic surgeries is escalating thanks to their advantages over the open surgeries. However, several complications can be observed following laparoscopy operation. Postoperative pain is a major concern in cholecystectomy surgeries. Pain can be both experienced in operated areas and radiated to the right shoulder. Acetazolamide is used for glaucoma, acute mountain sickness prophylaxis, and epilepsy in few patients with recurrent epilepsy. It seems that patients’ pain can be reduced by preventing carbonic acid production in abdomen after operation.. We aimed at evaluating if administration of acetazolamide preoperatively could affect early or late postoperative pain following laparoscopic surgery..Patients and In a randomized-controlled clinical trial study, 70 subjects (30 - 60 years) scheduled for laparoscopic cholecystectomy were included after obtaining a written informed consent. Patients were divided into two groups randomly (intervention and control). The intervention group received 5 mg/kg oral acetazolamide one hour before the operation. The control group did not receive any further medication.. Administration of a single dose of acetazolamide did not have any statistically significant impact on sleep quality (P = 1.000). Moreover, there was no statistically significant difference between groups regarding nausea and vomiting on single dose administration of acetazolamide (P = 1.000). Single dose of acetazolamide was associated with statistically significant decrease in shoulder pain immediately after laparoscopy (P = 0.017). However, there was no statistically significant difference regarding shoulder pain between the studied groups 2, 4, 6, 8, 10, 12, and 24 hours after laparoscopy. Single dose of acetazolamide did not significantly affect analgesic administration in 2, 4, 6, 8, 10, 12, and 24 hours after laparoscopy.. Single dose of acetazolamide was associated with statistically significant decrease in shoulder pain immediately after laparoscopy. However, this effect was limited to the first postoperative hours and it failed to reduce postoperative pain of right shoulder during 24 hours after the operation..

Context: Patients with undifferentiated systolic murmurs present commonly during the perioperative period. Traditional bedside assessment and auscultation has not changed significantly in almost 200 years and relies on interpreting indirect acoustic events as a means of evaluating underlying cardiac pathology. This is notoriously inaccurate, even in expert cardiology hands, since many different valvular and cardiac diseases present with a similar auditory signal..Evidence Acquisition: The data on systolic murmurs, physical examination, perioperative valvular disease in the setting of non-cardiac surgery is reviewed.. Significant valvular heart disease increases perioperative risk in major non-cardiac surgery and increases long term patient morbidity and mortality. We propose a more modern approach to physical examination that incorporates the use of focused echocardiography to allow direct visualization of cardiac structure and function. This improves the diagnostic accuracy of clinical assessment, allows rational planning of surgery and anaesthesia technique, risk stratification, postoperative monitoring and appropriate referral to physicians and cardiologists.. With a thorough preoperative assessment incorporating focused echocardiography, anaesthetists are in the unique position to enhance their role as perioperative physicians and influence short and long term outcomes of their patients..

Patients undergoing gynecology laparoscopy frequently experience shoulder pain as a common postoperative complication. Considering diaphragm stimulation in its pathophysiology, there are some advice to prevent or control this special form of referral pain.. The current study aimed to assess the prophylactic effect of preoperative administration of oral gabapentin to prevent Post Laparoscopic Shoulder Pain (PLSP) after laparoscopic ovarian cystectomy..Patients and In a randomized, double blind, placebo controlled trial 40 female patients who were candidates to have elective laparoscopic ovarian cystectomy, received uniformed capsules containing gabapentin 600 mg or placebo 30 minutes before anesthesia induction. All patients had the American Society of Anesthesiologists (ASA) Physical Status of I-II and none had pervious abdominal surgery. Thereafter, the presence of side effects and PLSP and its severity was assessed by Visual Analog Scale (VAS) in the beginning of surgery and 2, 6, 12 hours after the surgery.. Comparing the gabapentin (n = 20) and placebo (n = 20) groups, basic characteristics including age (P = 0.446), Body Mass Index (BMI) (P = 0.876), pregnancy history (P = 0.660), and surgery time (P = 0.232) were statistically similar. PLSP occurrence was less frequent in the gabapentin group (45%) compared with the placebo group (75%) (P = 0.053), while In gabapentin group the VAS scores were lower in 2(P = 0.004), 6 (P = 0.132), and 12 (P = 0.036) hours, post operatively.. Prophylactic gabapentin administration could be considered as an effective and safe intervention to reduce occurrence and severity of PLSP after gynecologic laparoscopic cystectomy..

Postoperative pain is one of the most common problems after hernia repair. Decrease in postoperative pain accelerates functional recovery, decreases duration of hospital stay and postoperative morbidity.. To compare postoperative analgesic effect of infiltration of magnesium versus bupivacaine into incision of inguinal hernia repair..Patients and In a double blind clinical trial, 80 patients’ candidates for elective inguinal hernia repair were enrolled. Right before closure of incision, in Bupivacaine group 5 mL Bupivacaine 0.5% added to 5 mL normal saline and in Magnesium group, 10 mL Magnesium sulfate 20% was infused subcutaneously. Pain score was measured using numeric rating score (NRS) at 1, 3, 6, 12 and 24 hours postoperatively. If NRS was above 3, 1 mg morphine was administered as rescue analgesic until patient felt comfortable or NRS < 3.. Postoperative pain scores at 1 and 3 hours were not significantly different between bupivacaine and magnesium groups (P = 0.21, 0.224; respectively). However, at 6 (P = 0.003), 12 (P = 0.028) and 24 (P = 0.022) hours postoperative, pain score (NRS) was significantly lower in bupivacaine group. Number of patients needed at least 1 dose of rescue morphine (P = 0.001), mean number of episodes asked for morphine during next 24 hours (P = 0.001) and total dose of morphine requirement (P = 0.01) were significantly lower in bupivacaine group.. Magnesium infiltration did not decrease total dose and number of episodes needed for morphine rescue analgesic. Bupivacaine infiltration into surgical site was more effective than magnesium sulfate infiltration in postoperative pain control..

Use of analgesics, especially opioids, before delivery during cesarean section for preventing hemodynamic changes after endotracheal intubation and postoperative analgesia is limited due to their adverse effects on the neonate.. The aim of this study was to investigate the effect of intravenous acetaminophen (paracetamol) in blunting hemodynamic responses to endotracheal intubation and postoperative pain in parturient undergoing cesarean section by general anesthesia..Patients and Eighty parturients undergoing cesarean section by general anesthesia were randomly divided to receive either 15 mg/kg intravenous paracetamol (n = 40) or normal saline (n = 40) fifteen minutes before endotracheal intubation. Mean arterial blood pressure (MAP) and pulse rates were compared at baseline and after intubation at one minute interval for five minutes between the two groups. The patients were also compared for postoperative pain intensity and analgesic requirement.. Patients in the saline group experienced more pain in the recovery room (VAS 7.0 ± 1.24 vs. 6.15 ± 2.27; P value = 0.041) and required more fentanyl intraoperatively (150 µg vs. 87.7 ± 75; P value < 0.01) and meperidine postoperatively (12.88 ± 20.84 mg vs. 1.35 ± 5.73; P value = 0.002) than the paracetamol group. Mean arterial pressure (MAP) changes were similar after intubation in the both groups (P value = 0.71), however, pulse rates showed greater changes following intubation in the saline group (P value = 0.01).. Intravenous acetaminophen administered before caesarean section reduced tachycardia after intubation, narcotic drugs administration during and after the operation and reduced pain in PACU..

Chronic pain tends to be difficult to manage because of its complex natural history and poor response to therapy. Recently, it has been reported that telecare management by nurses improved outcomes of patients with chronic pain.. The aim of this study was to investigate the effect of a telephone consultation approach partially based on a cognitive-behavioral approach on pain and quality of life (QOL) in patients with chronic pain in Japan..Patients and Telephonic consultation was provided by nurse care managers for the management of pain. They informed the patients how to correct or eliminate excessive fear of pain, improper thinking for treating pain, as well as how to control activity levels by appropriate pacing. We received 463 consultations about chronic pain; however, 153 patients allowed us to recall for follow-up assessment. Finally, we could evaluate the pain intensity for 121 patients and the EuroQOL 5 dimension (EQ-5D) for 37 patients at the initial call and on their condition at 3 to 6 months after that. Wilcoxon signed-rank test and Cohens’d were used for both analyses. We also asked them to rate, by feeling, marked signs of improvement, some improvement, no improvement, or deterioration in pain and QOL, depending on their condition 3 to 6 months after the initial call (n = 121).. The pain intensities were significantly decreased from 7.6 ± 2.0 at baseline to 5.7 ± 2.9 on follow-ups assessed by a numerical rating scale (range; 0 - 10, P < 0.001, effect size (ES); 0.76). The EuroQOL 5 dimension scores were also significantly improved after telephone intervention; 0.5 ± 0.2 to 0.6 ± 0.2 (range; 0 - 1, P < 0.001, ES; 0.65). Moreover, as a result of the consultation, approximately half of the participants felt an improvement in the intensity of pain and QOL.. Telephone consultation partially based on a cognitive-behavioral approach significantly reduced the intensity of pain and improved the QOL in patients with chronic pain in Japan..

Tracheal intubation using Storz’s C-Mac D-bladeTM videolaryngoscope is associated with difficult negotiation of the tracheal tube into the glottis due to steep angulation of its blade.. In this study, we hypothesized that TruflexTM articulating stylet with its ability to dynamically tailor the ETT shape to patients’ oropharyngeal anatomy would be better suited to the D-blade angulation and ease tracheal intubation compared to PortexTM intubation stylet..Patients and Following approval by the Ethical Issues Committee and informed consent, 218 ASA I and II patients of either sex were enrolled in this interventional, single-blind, randomized controlled trial. Tracheal intubation was performed following a uniform general anesthetic technique using the Storz’s C-Mac D-bladeTM videolaryngoscope aided by either TruflexTM articulating stylet or the PortexTM intubation stylet by an experienced anesthesiologist. The outcome measures included success or failure to intubate in the first attempt, total intubation time, hemodynamic disturbances, trauma if any and user satisfaction.. The number of patients in whom intubation was successful in the first attempt was significantly higher by using Truflex™ articulating stylet (99.1%) compared to PortexTM intubation stylet (90.0%; P-Value = 0.003). User satisfaction grade was significantly better while using TruflexTM articulating stylet (8.5 ± 0.88) compared to the PortexTM intubation stylet (8.23 ± 0.99; P-Value = 0.035). We did not observe any significant difference in total intubation time, hemodynamic disturbances or trauma.. Storz’s C-Mac D-bladeTM videolaryngoscope provides grade I Cormack and Lehane’s glottic view in 99.1% patients. First attempt successful tracheal intubation and user satisfaction significantly improved by TruflexTM articulating stylet compared to the PortexTM intubation stylet..

Suprascapular nerve block (SSNB) is commonly used in pain therapy for patients with chronic shoulder pain. The effect of SSNB on shoulder function has, however, not been investigated so far. If in shoulder function, i.e. the range of motion is increased after application of the nerve block, it can be expected that subsequent physiotherapy, besides being less painful, is also more effective in terms of restoring shoulder mobility.. Our aim was to evaluate the effect of SSNB on shoulder function, in patients with chronic shoulder pain..Patients and Patients were evaluated using the Constant-Murley Score (CMS) and number rating scale values for pain. The SSN was blocked using the Feigl approach, with 5 ml ropivacaine 0.5%. Shoulder function and pain were assessed 60 minutes and 24 hours after the block.. Totally, 20 patients completed the study. The CMS and pain scores significantly improved after the block.. The use of the modified lateral SSNB of Feigl significantly reduces pain and increases shoulder function, in chronic shoulder pain..

Patients with mandible deformity may die, as a result of airway management failures. The awake nasal fiberoptic intubation is known as the optimum intubation method, in the mentioned patients, although, in several cases, fiberoptic intubation fails.. The present case discusses a patient with severe deformity of mandible that was admitted for correction with free-flap. The following intubation techniques were used for her airway management, respectively: blind awake nasal intubation, awake oral fiberoptic and awake nasal fiberoptic, which failed all. We therefore decided to perform awake nasal intubation, with fiberoptic, in sitting position.. In this case, after failure of awake fiberoptic intubation, awake direct laryngoscopy and blind nasal intubation, finally awake nasal intubation in sitting position, using fiberoptic led to success..

Tension-type headache (TTH) is the most common primary headache affecting the general population, which is characterized by bilateral headache and mild to moderate pain. This disorder causes high levels of disability and recent scientific evidence suggests that manual therapy (MT) and therapeutic exercise are effective in reducing medication intake and decreasing the frequency and intensity of headaches in patients with TTH.. A 34-year-old woman was known to have chronic TTH. Initially, the patient presented moderate headaches 5 days per week, mechanical neck pain and no positive response to analgesics. A battery of self-reports was given to the patient to assess disability (using the Spanish versions of the Headache Impact Test-6 and the neck disability index), pain (visual analogue scale) and psychosocial issues (Spanish version of the pain catastrophizing scale) involved in the headaches. All measurements were taken four times during 161 days. Eleven sessions of treatment including MT, motor control therapeutic exercise (MCTE) and therapeutic patient education (TPE) were applied.. This biobehavioral-based multimodal physical rehabilitation treatment combining MT, TPE and MCTE produced a substantial reduction in pain intensity, pain catastrophizing, disability and the impact of headaches on patient’s life..