فهرست مطالب

Anesthesiology and Pain Medicine - Volume:7 Issue: 3, 2017
  • Volume:7 Issue: 3, 2017
  • تاریخ انتشار: 1396/04/02
  • تعداد عناوین: 16
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  • Fardin Yousefshahi, Oana Predescu, Juan Francisco Asenjo* Page 1
    Context: Despite recent advances in the understanding of the chronic pain concept, its diagnosis and management remains a daily challenge for clinicians and patients. Based on the published literature, this review discusses and tries to organize the current knowledge and the up-to-date clinical experience about the efficacy and safety of the use of intravenous lidocaine in treatment and prevention of chronic pain.
    Evidence Acquisition: To prepare this narrative review, we performed an in depth literature review using the PubMed searching engine. We extracted all relevant articles published in English, up to April 2016.
    Results
    Lidocaine, administered as transdermal patch or intravenous lidocaine, is a safe and effective modality in the treatment of post-herpetic neuralgia (PHN), complex regional pain syndrome, as well and for prevention of chronic pain. It may be effective in the management of neuropathic pain syndromes, chronic pain, post-operative pain, and refractory cancer pain.
    Conclusions
    Intravenous lidocaine and lidocaine patch are effective and safe for the treatment of several chronic or neuropathic pain syndromes. The use of lidocaine during surgery could prevent the development of some chronic post-surgical pain syndromes.
    Keywords: Lidocaine, Chronic Pain, Neuropathic Pain, Post, Herpetic Neuralgia, Complex Regional Pain Syndrome
  • Farnoush Farzi, Ali Mirmansouri *, Zahra Atrkar Roshan, Bahram Naderi Nabi, Gelareh Biazar, Shima Yazdipaz Page 2
    Background
    Care of obstetric patients has always been a challenge for critical care physicians, because in addition to their complex pregnancy-related disease, fetal viability is considered.
    Objectives
    The aim of this study was to review the admission indications, clinical characteristics and outcomes of obstetric patients, admitted to the intensive care unit of Alzzahra teaching hospital affiliated to Guilan University of Medical Sciences, Rasht, Iran.
    Methods
    This retrospective cohort study was conducted on pregnant /post-partum (up to 6 weeks) patients admitted to the ICU over a 5-year period from April 2009 to April, 2014.
    Results
    Data from 1019 subjects were analyzed. Overall, 90.1% of the patients were admitted in the postpartum period. The most common indications for admission were pregnancy related hypertensive disorders (27.5%) and obstetric hemorrhage (13.5%). Epilepsy (5.4%) and cardiac disease (5.2%) were the most common non-obstetric indications.
    Conclusions
    Pregnancy-related hypertensive disorders and obstetric hemorrhage were the main reasons for admission, and epilepsy and cardiac disease were the most common non-obstetric indications. Efforts must be concentrated on increasing antenatal care.
    Keywords: Obstetric Patients, Intensive Care Unit, Admission Indication, Outcome
  • Seyed Hossein Sadrolsadat, Fardin Yousefshahi, Abbas Ostadalipour, Fatemeh Zahra Mohammadi, Jalil Makarem * Page 3
    Background
    Nowadays, pain, nausea, and vomiting are regarded as important complications of anesthesia and surgery. The current study aimed at assessing the effect of preemptive intravenous acetaminophen on control of pain, nausea, vomiting, shivering, and drowsiness following the general anesthesia for retina and/or vitrectomy surgeries.
    Methods
    In a randomized, double-blind, clinical trial, 83 candidates for retina or vitrectomy eye surgery under general anesthesia were distributed into 3 groups: A) 41 patients in the control group who received 100 mL of normal saline just before the surgery and 100 mL of normal saline 20 minutes before the end of surgery; B) 21 patients in the preemptive group who received acetaminophen 15 mg/kg in 100 mL normal saline just before the surgery and 100 mL normal saline 20 minutes before the end of surgery; C) 21 patients in the preventive group who received 100 mL normal saline just before the surgery and acetaminophen 15 mg/kg in 100 mL normal saline 20 minutes before the end of surgery. Pain, nausea, vomiting, and shivering were assessed at the recovery and 2, 4, and 24 hours after the operation. Anesthesia emergence situation was assessed after arrival in the recovery room by the Richmond agitation-sedation scale (RASS) questionnaire. Blood pressure and heart rate were recorded before anesthesia induction, just after intubation, before extubation, and on discharge from the recovery room.
    Results
    Total intraoperative fentanyl, duration of operation, and duration of anesthesia were not different among the studied groups. Vital signs were not statistically different among the groups at before anesthesia induction, just after intubation, before extubation, and on discharge from the recovery room. Thirty-three patients in the control group (87.8%), 11 in preemptive (52.4%), and 14 in preventive groups (66.7%) needed acetaminophen in the first 24 hours after the surgery (P value = 0.008). Pain scores measured by visual rating scale (VRS) was lower in the preemptive and preventive groups, compared with those of the control group, in the recovery (P value = 0.006), 2 hours after the surgery (P value = 0.008), and 4 hours after the surgery (P value = 0.012), but not in 24 hours after the operation (P value = 0.1).
    Conclusions
    Intravenous acetaminophen administered as preemptive or preventive medication was effective and safe to control acute postoperative pain and analgesic request after the vitrectomy eye surgery.
    Keywords: Intravenous Acetaminophen, Postoperative Pain, Vitrectomy
  • Mats De Jaeger *, Robbert-Jan Van Hooff, Lisa Goudman, Alexis Valenzuela Espinoza, Raf Brouns, Martine Puylaert, Wim Duyvendak, Maarten Moens Page 4
    Background
    Spinal cord stimulation (SCS) is a proven and effective treatment for neuropathic pain conditions such as failed back surgery syndrome (FBSS). The hypothesis that different settings for SCS parameters activate unique, pain-relieving mechanisms has boosted the development of various SCS paradigms. High density spinal cord stimulation (HD-SCS) is one of those promising, novel stimulation forms characterized by subthreshold stimulation, delivering more pulses per second and a higher pulse density to the spinal cord than conventional SCS.
    Objectives
    The aim of DISCOVER is to gather evidence about the effectiveness, feasibility, and (possible) side effects of HD stimulation.
    Methods
    The prospective, non-interventional, multi-center, clinical study, DISCOVER, is currently restricted to Belgium where 19 neuromodulation centers were selected. Patient recruitment started in October 2016 and is expected to end in October 2017. Subjects included are (1) patients with insufficient pain relief from conventional SCS or (2) neurostimulation-naïve patients suited for SCS. Patients will be assessed 1 month, 3 months, and 12 months after conversion to HD-SCS settings. Each patient’s visit will include: a numerical rating scale (NRS), Oswestry disability index (ODI), Pittsburgh sleep quality index (PSQI), EQ-5D, a pain map, registration of SCS settings, and a list of used pain medication.
    Conclusions
    Although promising results have been reported, adequate registration of its effectiveness and (possible) side-effects remains an unmet need. Main results are expected in 2019.
    Keywords: Spinal Cord Stimulation, High Density, Failed Back Surgery Syndrome, Neuromodulation
  • Reza Akhondzade *, Sholeh Nesioonpour, Mohammadreza Gousheh, Farhad Soltani, Mohsen Davarimoghadam Page 5
    Background
    Previous studies have been conducted to evaluate the effect of different adjuvants on brachial plexus block.
    Objectives
    This study investigated the effect of adding magnesium sulfate to lidocaine on postoperative pain in upper limb surgeries by supraclavicular brachial plexus block under ultrasound guidance.
    Methods
    This study was carried out on patients who were candidate for upper limb surgeries. This was a controlled double-blind study conducted on a number of 52 patients aged 18 - 75 years with ASA class I or II. The first group (M) received lidocaine 1% (4 mg/kg) plus fentanyl 50 micg and magnesium sulfate 20% (5 mL) while the second group (N) received lidocaine 1% (4 mg/kg) plus fentanyl 50 micg and normal saline (5 mL) to supraclavicular brachial plexus block under ultrasound guidance. Postoperative pain was evaluated by visual analog scale (VAS) until 24 hours. Sensory and motor blocks onset and duration, rescue analgesics, hemodynamic variables, and side effects were recorded for all the patients.
    Results
    Postoperative VAS values at 24 hours were significantly lower in group M than group N (P
    Conclusions
    The addition of magnesium sulfate to lidocaine decreased the postoperative pain and increased the onset and duration of sensory and motor blocks in supraclavicular brachial plexus block under ultrasound guidance in upper limb surgeries.
    Keywords: Magnesium Sulfate, Postoperative Pain, Supraclavicular Block, Ultrasound
  • Hany Mahmoud Yassin *, Ahmed Tohamy Abd Elmoneim, Hatem El Moutaz Page 6
    Background
    Ultrasound-guided rectus sheath blockade has been described to provide analgesia for midline abdominal incisions. We aimed to compare thoracic epidural analgesia (TEA) and rectus sheath analgesia (RSA) with respect to safety and efficacy.
    Methods
    Sixty patients who underwent elective laparotomies through a midline incision were assigned randomly to receive either continuous TEA (TEA group, n = 31) or intermittent RSA (RSA group, n = 29). The number of patients who required analgesia, the time to first request analgesia, the interval and the cumulative morphine doses consumption during 72 hours postoperatively, and pain intensity using visual analog score (VAS) at rest and upon coughing were reported in addition to any side effects related to both techniques or administered drugs.
    Results
    While 17 (54.84 %) patients were in the TEA group, 25 (86.21%) patients in the RSA group required analgesia postoperatively, P = 0.008. Cumulative morphine consumed during the early 72 hours postoperatively median (interquartile range) = 33 mg (27 - 39 mg), 95% confidence interval (28.63 - 37.37 mg) for the TEA group. While in the RSA group, it was 51 mg (45 - 57 mg), 95% CI (47.4 - 54.6 mg), P 0.05. The time to the ambulation was significantly shorter in the RSA group (38.47 ± 12.34 hours) as compared to the TEA group (45.89 ± 8.72 hours), P = 0.009. Sedation scores were significantly higher in the RSA group, only at 12 hours and 24 hours postoperatively than in TEA group, with P = 0.041 and 0.013, respectively. The incidence of other morphine-related side effects, time to pass flatus, and patients satisfaction scores were comparable between both groups.
    Conclusions
    Continuous TEA had better opioid sparing effects markedly during the early 72 hours postoperatively than that of intermittent RSA with catheters inserted under real-time ultrasound guidance, both had comparable safety perspectives, and RSA had the advantage of early ambulation. RSA could be used as an effective alternative when TEA could not be employed in patients undergoing laparotomies with an extended midline incision, especially after the first postoperative day.
    Keywords: Postoperative Analgesia, Rectus Sheath Analgesia, Midline Incision Abdominal Surgery, Thoracic Epidural Analgesia
  • Pryambodho Pryambodho *, Alfan Mahdi Nugroho, Desy Januarrifianto Page 7
    Background
    Success of spinal anesthesia in pregnant females is strongly influenced by the position of the patient at the time of spinal insertion. Pendant position is a new position introduced to increase the intervertebral spaces. The current study aimed at comparing successful spinal puncture among the patients with pendant position in comparison with the ones with traditional sitting position for the elective caesarean section.
    Methods
    The current study was a non-blinded, randomized controlled trial (RCT) (registration code: NCT02753660 (ClinicalTrial.gov) on pregnant females undergoing spinal anesthesia. The participants were divided into 2 groups by the random consecutive sampling method; group A (pendant position) and group B (traditional sitting position). The successful placement of spinal needle was determined by the number of attempts, the amount of bone contact, and the time of spinal puncture. The inclusion criteria were pregnant females aged 18 to 45 years, body mass index (BMI) of 18 to 35 kg/m2, and the physical status I to III, based on American society of anesthesiologists classification (ASA).
    Results
    Following the approval of the ethical committee, 308 subjects were enrolled in the study. The rate of successful puncture on the 1st attempt of group A was significantly high (92% vs. 78%, P value = 0.001). Additionally, group A had significantly less total amount of bone contact (185 vs. 421, P value
    Conclusions
    Pendant position was significantly better than traditional sitting position to provide successful 1st attempt spinal puncture in pregnant females undergoing cesarean section.
    Keywords: Duration of Spinal, Pendant Position, Spinal, Bone Contact, Spinal Needle Puncture
  • Manzumeh Shamsi Meymandi, Fariborz Keyhanfar *, Gholam Reza Sepehri, Gioia Heravi, Omid Yazdanpanah Page 8
    Background
    Pregabalin has shown remarkable antinociceptive effects in neuropathic pain; however, its efficacy against acute and visceral pain remained controversial.
    Objectives
    The present study aimed at investigating the involvement of N-methyl-D-aspartate (NMDA) receptors in the antinociceptive effect of pregabalin in both acute and visceral pain using and comparing hot plate test and writhing test in male mice.
    Methods
    NMDA (15 and 30 mg/kg), as an agonist or MK801 (0.02 and 0.05 mg/kg) as an NMDA receptor (NMDAR) antagonist, were injected intraperitoneally either alone or 15 minutes before a dose of pregabalin that produced almost 30% antinociception (100 mg/kg in hot plate test and 5 mg/kg in writhing tests). Then, the percentage of maximal possible effect (MPE%) at the 30th and 60th minutes in hot plate test and effect percentage (E%) in writhing test were measured and compared as antinociceptive indexes.
    Results
    In hot plate test, pretreatment with MK801 (0.05 mg/kg) significantly increased antinociceptive effect of 100 mg/kg pregabalin, but pretreatment with NMDA did not result in any effect. Pretreatment with MK801 in writhing test significantly increased the antinociceptive effect of 5 mg/kg pregabalin (In contrast to 30 mg/kg NMDA that significantly decreased it.). NMDA induced antinociception reduction or MK801 increased antinociception in writhing test were significantly higher than what was observed in hot plate test.
    Conclusions
    Our results suggested that pregabalin antinociception in acute and visceral pain is mediated through NMDA receptors. Although this effect depends on the dose of NMDAR ligand, it is more pronounced in the behavioral response in the writhing test.
    Keywords: Pregabalin, NMDA, Antinociception, MK801, Writhing test, Hot Plate
  • Jalil Makarem, Seyed Mohammad Mireskandari *, Afshin Jafarzadeh, Laya Rahbar Nikoukar, Sara Aghaii Page 9
    Background
    Pruritus is a troublesome side effect of intrathecal opioids. Midazolam can reinforce GABA-mediated inhibition of the medullary dorsal horn neurons, and thus theoretically has potential to suppress opioid-induced pruritus.
    Objectives
    This prospective double-blinded randomized trial aimed at comparing the effects of propofol, midazolam, and a combination of the two on the prevention of pruritus induced by intrathecal sufentanil.
    Methods
    Eighty-four patients undergoing spinal anesthesia with 3 mL hyperbaric bupivacaine 0.5% and 5 μg sufentanil (1 mL) were randomly allocated to one of the three study groups: Group 1, who were administered 20 mg intravenous (IV) propofol bolus, then 50 μg/kg/min IV infusion; Group 2, who were administered 0.03 mg/kg IV midazolam bolus, then 0.02 mg/kg/h IV infusion; and Group 3, who were administered 10 mg IV propofol and 0.015 mg/kg IV midazolam bolus, then 25 μg/kg/min propofol and 0.01 mg/kg/h midazolam IV infusion. The incidence rates and severity of pruritus were assessed intraoperatively and postoperatively for 24 hours.
    Results
    The Ramsay Sedation Score was highest for the propofol group throughout the duration of the anesthetic process. Overall, 17 patients in the propofol group (60.7%), eight patients in the midazolam group (28.6%), and nine patients in the propofol-midazolam group (32.1%) developed pruritus (P = 0.027). Intraoperative pruritus was observed in seven patients in the propofol group (25%), two patients in the midazolam group (7.1%), and five patients in the midazolam-propofol group (17.9%) (P = 0.196). Postoperative pruritus developed in 12 patients in the propofol group (42.9%), six patients in the midazolam group (21.4%), and four patients in the midazolam-propofol group (14.3%) (P = 0.041). There was no significant difference between the groups with respect to the severity of pruritus (P > 0.05).
    Conclusions
    This study showed that in comparison with propofol, the administration of 0.03 mg/kg IV midazolam bolus followed by 0.02 mg/kg/h could be more effective in the prevention of intrathecal sufentanil-induced pruritus without increasing sedation and other side effects.
    Keywords: Midazolam, Propofol, Sufentanil, Pruritus, Spinal Anesthesia
  • Seyed Tayeb Moradian, Yaser Saeid, Abbas Ebadi, Ali Hemmat, Mohammad Saeid Ghiasi * Page 10
    Background
    Pulmonary complications are common following cardiac surgery and can lead to increased morbidity, mortality, and healthcare costs. Atelectasis is the most common respiratory complication following cardiac surgery. One of the most important methods for reducing pulmonary complications is supportive care with protective ventilation strategies. In this study, we aimed to assess the effect of adaptive support ventilation (ASV) on atelectasis in patients undergoing cardiac surgery.
    Methods
    In this single-blind randomized clinical trial, 115 patients, undergoing coronary artery bypass grafting, were randomly allocated into 2 groups: 57 patients in the intervention and 58 patients in the control group. Patients in the intervention group were weaned with ASV, while patients in the control group were managed using synchronized intermittent mandatory ventilation (SIMV) and pressure support. The incidence of atelectasis, duration of mechanical ventilation, manual ventilator setting, arterial blood gas measurements, and length of hospital stay were compared between the groups.
    Results
    The incidence of atelectasis, number of changes in the manual ventilator setting, number of alarms, and length of hospital stay reduced in the intervention group. However, duration of mechanical ventilation and number of ABG measurements were not significantly different between the groups.
    Conclusions
    The ASV mode could reduce the incidence of atelectasis and length of hospital stay. However, it did not reduce the duration of mechanical ventilation. It seems that ASV is not a superior mode for faster extubation.
    Keywords: Adaptive Support Ventilation, Coronary Artery Bypass Grafting, Atelectasis, Ventilator Weaning
  • Mohammadreza Kamranmanesh, Babak Gharaei * Page 11
    Background
    Use of laryngeal mask airways (LMAs) has been advocated for children with upper respiratory tract infection (URI). However, no randomized trial has yet compared intravenous corticosteroids versus placebo in these patients.
    Objectives
    We hypothesized the lower incidence of postoperative cough (as the primary outcome) with intravenous corticosteroid versus placebo in pediatric patients with mild URI, who were anesthetized with LMA.
    Methods
    A total of 210 patients with mild URI, aged 1 - 6 years, were included. The patients underwent full ophthalmic examination immediately (within few days). They were randomized to receive either intravenous corticosteroids (1 mg/kg of hydrocortisone and 0.1 mg/kg of dexamethasone 10 minutes prior to anesthesia induction) or placebo. Anesthesia was induced with sevoflurane. Following LMA insertion, the patients were maintained on anesthesia with spontaneous ventilation on N2O, O2, and 3% sevoflurane; LMA was removed under deep anesthesia. The outcomes were evaluated during anesthesia, recovery, and the first postoperative week.
    Results
    A total of 204 patients completed the trial. Cough, which was designated as the primary outcome, was not significantly different among patients receiving corticosteroids and placebo (31% vs. 34%; P = 0.7). Also, the incidence of laryngospasm (16% vs. 14%), apnea (9% VS 5%), desaturation (4% vs. 5%), bronchospasm (14% vs. 7%), vomiting (4% vs. 6%), and postoperative symptoms (8% vs. 7%) was not significantly different between the groups.
    Conclusions
    Based on the present research, intravenous injection of corticosteroids has no beneficial effects for pediatric patients with minor uncomplicated URI (without a history of allergy), undergoing LMA anesthesia.
    Keywords: Upper Respiratory Tract Infection, Child, Anesthesia, Corticosteroid
  • Poupak Rahimzadeh, Farnad Imani, Nasim Nikoubakht, Zahra Koleini, Seyed Hamid Reza Faiz *, Azadeh Sayarifard Page 12
    Background
    Memantine is an N-methyl-D-Aspartate (NMDA) antagonist. By transferring acute postoperative pain, the NMDA channels may lead to active excess and neuropathic pain.
    Objectives
    This study attempted to investigate the effect of preoperative use of single oral dose of memantine in controlling Dacryocystorhinostomy (DCR) postoperative pain.
    Methods
    A double-blind clinical trial was conducted on 60 patients undergoing DCR. On arrival at the operating room, the memantine group received 20 mg of oral memantine and the control group received placebo. The severities of pain by visual analogue scale (VAS) and sedation by Ramsy Scale were measured immediately 1, 2, and 6 hours after the operation. The drug’s side effects were recorded.
    Results
    The pain scores of patients in the recovery in 1, 2, and 6 hours after operation were significantly lower in the memantine group than the placebo group (P
    Conclusions
    The oral single-dose 20 mg of memantine administered before DCR can reduce postoperative pain compared with placebo.
    Keywords: Dacryocystorhinostomy, Pain, Postoperative, Memantine, Placebo
  • Alexander E. Grant, Eric S. Schwenk *, Marc C. Torjman, Richard Hillesheim, Antonia F. Chen Page 13
    Background
    Multimodal analgesia featuring peripheral nerve blocks decreases postoperative pain for patients undergoing primary total knee arthroplasty (TKA). Many anesthesiologists and surgeons advocate for the use of adductor canal blocks (ACBs) for analgesia, which result in less weakness compared to femoral nerve blocks. Few data exist to guide analgesic management in total knee revision (TKR), considered to be more painful than primary TKA. We hypothesized that TKR patients with a continuous ACB would use more opioids than primary TKA patients who received the same analgesic regimen.
    Methods
    A retrospective study of 58 TKA and TKR patients who received ACBs in a multimodal protocol was conducted from 1/2014 to 3/2016. Exclusion criteria included patients who took ≥ 20 mg of morphine daily preoperatively. The primary outcome was 48-hour opioid consumption. Secondary outcomes included pain ratings, catheter boluses, and catheter infusion rate changes over 48 hours.
    Results
    For the primary outcome of 48-hour opioid consumption, there was no significant difference between groups. Postoperative pain ratings were not significantly different during the overall 48-hour time period. There were also no significant differences in catheter boluses and infusion rate changes. Least squares regression analysis revealed a positive correlation between number of previous knee surgeries and postoperative pain level.
    Conclusions
    Patients who underwent TKR with continuous ACB experienced a similar postoperative analgesic course as primary TKA patients. Within the TKR cohort, the number of previous revisions was positively associated with pain level. Larger prospective studies with TKR are needed to confirm these findings.
    Keywords: Adductor Canal Block, Joint Revision, Multimodal Treatment, Nerve Block, Total Knee Replacement
  • Behzad Nemati Honar, Alireza Mirkheshti *, Elham Memary Page 14
    A 25-year-old man underwent an excision of a thigh mass under general anesthesia without any complication. After the operation, he developed oxygen desaturation requiring a jaw thrust maneuver. A rapidly expanding hematoma on the right side of the neck was formed shortly after the application of the maneuver. The patient was returned to the operation room for a neck exploration. Damage to the facial artery and vein was noted. Further evaluations confirmed the diagnosis of Neurofibromatosis type 1 (NF-1). It is recommended that considering the probable risk of arising hematoma in NF-1 patients, application of jaw thrust maneuver should be performed meticulously.
    Keywords: Airway Management, Anesthesiology, Emergencies, Hematoma, Neurofibromatoses
  • Sara Pedrosa *, Nuno Lareiro, Pedro Amorim Page 15
    Introduction
    Narcoleptic patients may be at increased risk of prolonged emergence, postoperative hypersomnia, apneic episodes, and sleep paralysis after general anesthesia. Modafinil is the first-line treatment, however, the implication it has on general anesthesia is not clear. This report present 2 cases of narcoleptic patients medicated with modafinil that were submitted to total intravenous anesthesia for neurosurgical procedures.
    Case Presentation
    Informed consent was obtained from both patients. Clinical information was obtained from patients’ interviews and medical records. Intraoperative data was collected using Datex Ohmeda, Bispectral index, Entropy, and LiDCO rapid monitors, and exported to excel sheets to allow its analysis. Both patients maintained modafinil on the day of surgery and were not administered sedative premedication. Propofol was administered by bolus during induction of anesthesia. In one of the patients, the predicted cerebral concentration of propofol required for loss of consciousness was high. Anesthesia was maintained with remifentanil and propofol by target controlled infusion and titrated according to bispectral index (BIS), entropy, and analgesia nociception index (ANI). During the surgical procedure, the patients did not require vasopressors. Emergence from anesthesia was very fast and no narcoleptic event occurred postoperatively.
    Conclusions
    Sedative premedication should be avoided and the use of short-acting anesthetic agents, such as propofol and remifentanil through target-controlled infusion most likely improves titration of anesthesia. The continuation of modafinil preoperatively might have contributed to the rapid emergence, yet, might also have been responsible for the high cerebral concentration of propofol that was required for loss of consciousness in one of the patients.
    Keywords: Narcolepsy, Cataplexy, Sleep Paralysis, Modafinil, Anesthesia Intravenous, Neurosurgery, Consciousness Monitors