Anesthesiology and Pain Medicine
Volume:9 Issue: 4, Aug 2019

The term pain in neonates is emerged in recent decades. However, studies on pain in neonates are still limited and have various indicators. In addition, the term pain still often overlaps with stress in various studies and clinical circumstances. The concepts of pain and stress in the neonates need to be clarified to be better understood and then applied to improve neonates’ quality of life. Therefore, the current study aimed at clarifying the concept of pain in neonates.  The current study employed the concept analysis approach developed by Walker and Avant. The authors reviewed articles from JSTOR, ScienceDirect, Proquest, Sage, Cochrane, and Springer databases from 1980 to 2016 using keywords pain, stress, neonatal, neonates, and quality of life. Pain had attributes such as tissue damage, physiological changes, metabolic changes, and behavioral changes. Stress had attributes such as physiological changes, metabolic changes, and behavioral changes. Attributes of pain and stress have similarities and differences. The main difference is the stimulus that induces a response. Pain has an attribute of tissue damage, whereas stress is not always due to tissue damage. The attributes of physical, metabolic, and behavioral changes between pain and stress are similar.

There are meta-analyzes in adults demonstrating the benefits of using gabapentin to improve postoperative pain in orthopedic surgeries. In pediatrics, it has never been studied. The aim of this study was to evaluate the use of gabapentin 10 mg/kg, orally, in postoperative analgesia, hemodynamic stability and its pre/postoperative anxiolytic effect in children subjected to unilateral inferior limb surgery. We performed a double-blinded, randomized study. 84 patients in Albert Sabin Children’s Hospital were selected for elective surgery that were divided into 2 groups: gabapentin group, who received gabapentin 1 to 2 hours before the procedure and the control group. Both groups were submitted to the same general anesthesia protocol with 0.125% bupivacaine femoral and sciatic block. Patients received scheduled dipyrone and morphine was used as the rescue analgesic up to 2/2 h. Postoperative pain was assessed using a scale appropriate for age (CRIES, CHIPPS or Wong-Baker face scale). We registered hemodynamic parameters, analgesic consumption and pre/postoperative anxiolytics. A decrease in pain intensity in the 4th and 8th postoperative hours was observed in gabapentin group, both groups had the same opioid consumption. Children in the gabapentin group had an odds ratio of 25.6 for preoperative sedation and gabapentin promoted reduction of postoperative agitation. During orotracheal intubation the gabapentin group exhibited attenuation of the hemodynamic response. Gabapentin was superior to placebo in reducing postoperative pain. Children who received gabapentin were more sedated in the operating room, less agitated in the postoperative period and the autonomic response to intubation was reduced.

Flexible laryngeal mask airway may be used instead of the endotracheal tube in children presented for elective repair of tongue trauma, as it may shorten the time for extubation and recovery with the amelioration of stress response to airway management. This study aimed to evaluate the extubation time and hemodynamic response to the endotracheal tube or flexible laryngeal mask airway in children presented for tongue trauma repair. The study recruited 90 children presented for elective repair of tongue trauma that were randomly assigned into the following groups: the ETT group for which the airway was controlled by a cuffed endotracheal tube and the LMA group for which the airway was controlled by a flexible laryngeal mask. The intubation time, surgical time, total anesthesia time, extubation time, recovery time, changes in the hemodynamic parameters, and the incidence of complications were measured. The use of flexible laryngeal mask airway instead of endotracheal tube significantly decreased the extubation time to 7.47 ± 2.74 min (P < 0.0001) and the recovery time to 52.67 ± 11.16 min (P = 0.001) while no significant differences were observed in the intubation time (P = 0.874), surgical time (P = 0.411), and total anesthesia time (P = 0.725). In addition, the changes in the hemodynamic parameters were significantly lower with flexible laryngeal mask airway both during airway securing and at the start of the surgery (P < 0.05). Moreover, it significantly decreased the incidence of postoperative cough, stridor, and sore throat (P = 0.039, 0.006, and 0.027, respectively). The flexible laryngeal mask airway can be used instead of the endotracheal tube in children undergoing the repair of tongue trauma, as it decreases the extubation time, recovery time, and hemodynamic changes to the airway control.

Anterior cruciate ligament (ACL) reconstruction is an extremely common surgery in sports medicine and orthopedic surgery. This surgery requires creating tunnels in bones (femur and tibia), which is often associated with severe pain and thus general or neuraxial anesthesia should be applied to mitigate pain and anxiety. This paper follows our previous case report of hypnoanesthesia in hand surgery, discussing the application of hypnosis as a non-pharmacologic intervention for controlling intraoperative and postoperative pain and anxiety, which can contribute to postoperative recovery of patients with ACL surgery. According to the results of this study, it seems better to teach hypnosis as a pain control protocol to anesthesia residents and pain service staff. Also, hypnosis can be considered an anxiety reduction strategy in perioperative phases and also useful for postoperative pain management.

Primary headaches are one of the most troubled chronic diseases. Headaches interfere within the various dimensions of the patient’s life. Coping strategies that aim to be attention focused (e.g., mindfulness) may moderate pain-related emotional and physical interference. This investigation examined the relationship between mindfulness and pain intensity with physical and emotional interference and the subsequent aim was to analyze the role of mindfulness and headache severity combination in the prediction of pain-related interference. This correlational study was conducted during years 2017 to 2018 at Imam Hossein Hospital of Tehran province. Eighty-five patients (56 females and 29 males), who had one type of primary headache were selected through purposive sampling after the diagnosis by a neurologist. The data were collected through the brief pain inventory (BPI) and the mindful attention awareness scale (MAAS). All data were analyzed using descriptive statistics. Bivariate correlation matrix and hierarchical stepwise linear regression statistics were used. The correlational analysis of the results indicated significant association between mindfulness (MAAS) and pain severity (BPI) (P < 0.01) as well as the findings of the study point to the significant relationship between mindfulness and both physical and emotional pain-related interference (P < 0.01). The results of stepwise linear regression indicated that pain severity explains only 1% of the total score in emotional pain-related interference (P = 0.003 and ΔF (1 and 83) = 9.22, ΔR2 = 0.11). Adding mindfulness to the model led to a 43% increase of the explained variance (R2 Change = 0.34). In physical interference, although pain severity was able to predict pain interference (P = 0.01 and ΔF (1 and 83) = 7.09, ΔR2 = 0.07), a combination model justifies 10% of the interference variance that was not statistically meaningful (P = 0.08, ΔR2 = 0.103). This result is a further support that Mindful Awareness contributed to emotional pain-related interference prediction. This result can explain the role of attention focused and mindful awareness in primary headache pain adjustment.

Osteoarthritis (OA) is a progressive disease of the joints, leading to decreased function and disability. The study aimed to investigate the effect of self-management (SM) program on disability index and pain in aging men with knee OA. The study included an SM group and a control group. Given the sample size of the previous studies, 83 patients were recruited. The study tools included a demographic profile questionnaire, visual analogue scale (VAS), and HAQ 8-item DI. The intervention included 10 SM sessions for patients in the SM group (8 sessions of in-person intervention and 2 sessions of telephone intervention). Patients were placed in groups of 7, and the sessions were held weekly each for a period of 45 to 60 minutes. Data were analyzed using descriptive and analytical tests by SPSS V. 16 software. The two groups(SM and control group) were homogeneous in terms of demographic characteristics (P > 0.05). The mean (SD) disability score was 19.12 (1.92) in the SM group before the intervention, which reduced to 14.70 (1.63) after the intervention (P = 0.000, T = 10.02). The mean (SD) pain score, was 9.19 (0.71) in the SM group before the intervention, which reduced to 6.48 (0.84) after the intervention (P = 0.000, T = 18.15). Training can help patients perform SM measures and improve their health status by enhancing the information needed for the disease.

Recent articles about the topic of the anesthetic agents-related neurotoxicity have currently attracted the attention to the issue in the anesthesiology community. However, specialists in other fields should also be aware of this potential risk. This study aimed to evaluate the knowledge and practice of physicians at Guilan academic hospitals regarding general anesthesia-related neurotoxicity. Firstly, the responsible anesthesia resident explained the purpose of this work to Guilan faculty and residents and if they agreed to participate a questionnaire containing 12 items was filled via a face to face interview. A response rate of 100% was achieved (271 responders from 271 eligible study responders). Also, 89 (33.1%) responders were attending, 180 (66.9%) were residents, 112 (41.6%) were female, and 157 (58.4%) were male. The mean years of experience was 8.8 ± 4.82 (2 - 28 years). According to the achieved data, the majority of the precipitants did not believe in GA toxicity. This paper revealed that the current curriculum does not sufficiently address the anesthesia-related neurotoxicity problem. Indeed, the need for training and communication with non-anesthesia medical colleagues was highlighted.

Children with sensorineural hearing loss are at risk of cardiac electrophysiologic abnormalities. Inhalational Sevoflurane induction in these children can cause QT prolongation.

In order to evaluate the safety of inhalational induction of anesthesia with sevoflurane in children with sensorineural hearing loss, who are candidates for cochlear implant, its electrophysiologic effects was compared with intravenous induction of anesthesia with propofol.

In this double-blind randomized clinical trial, 61 children aged between one and eighteen years old, who were candidates for cochlear implantation, were randomly allocated to groups receiving anesthesia with sevoflurane (n = 32) or propofol (n = 29) for induction of anesthesia. Two 12-leads ECG were taken from all of patients before and after induction and QTc, Tp-e interval, and JTc were measured and compared.

Two cases, who had pre-induction QTc longer than 500 ms were excluded from the study. Patients had similar age (102.58  87 versus 101.46  67 months, P = 0.95) and gender (males: 48.3% versus 56.3%, P = 0.53) distribution. The researchers observed significant post induction difference in QTc values between these groups (propofol 422.5  40, sevoflurane 445.0  29, P = 0.016). There was no significant difference in the percent QTc and Tp-e changes in propofol and sevoflurane groups. Greater percentage of patients with increased Tp-e interval (> 100 ms) in the sevoflurane group than the propofol group was also seen. There was no significant long QTc difference (QTc > 500msor more than 60msincrease from baseline) after induction of anesthesia in the sevoflurane group compared to the propofol group (15.6% versus 13.8%, P = 0.84).

After electrophysiological evaluations in children with sensorineural hearing loss, in patients whose pre-induction QTc is not longer than 500 ms, propofol seems safer than inhalational sevoflurane for induction of anesthesia.

Epidural block approach and drugs are common options for improving the sensory and motor block duration and postoperative pain management.

The study aimed to compare the analgesic effects of dexmedetomidine and morphine as adjuvants to bupivacaine for epidural anesthesia in leg fracture surgery.

This prospective clinical trial was conducted on patients (n = 80, age range: 18 - 60 years) categorized as ASA class I or II. After a clinical examination, the patients were allocated to receive either lumbar epidural bupivacaine + morphine (BM) (12 mL bupivacaine 0.5% + morphine 2 mg) or bupivacaine + dexmedetomidine (BD) (12mLbupivacaine 0.5% + dexmedetomidine 1g/kg). After drug administration, the sensory block level was assessed at 2-min intervals using the Cold Swab method until it reached the T12 level. At the T12 level of sensory block, the surgery began when motor block reached grade 3 of the modified Bromage scale.

The BD group had a significantly shorter time to reach the sensory and motor block than the BM group (P < 0.001). The duration of sensory and motor block was significantly longer in the group BD than in the BM group (P < 0.001). Moreover, the BD group showed lower VAS scores (P < 0.0001) and longer time to first analgesia demand than the BM group.

Combined bupivacaine + dexmedetomidine prolongs the sensory and motor block duration and controls postoperative pain more effectively, indicating that it is an appropriate combination for epidural anesthesia.

Prevention and optimal treatment of postoperative bleeding are of great clinical importance in various types of surgeries including coronary artery bypass graft (CABG). Reducing the amount of bleeding will reduce the complications subsequent to blood transfusion. The positive effects of coagulation factors, especially fibrinogen, after cardiovascular bypass could have beneficial effects due to reduced bleeding and less need for blood transfusion. However, different studies have reported controversial findings.

The present study aimed to evaluate the effect of prophylactic administration of fibrinogen on blood loss in patients undergoing CABG surgery to achieve more accurate clinical outcomes.

This was a double-blind randomized clinical trial conducted on 36 patients hospitalized in Ahvaz Imam Khomeini Hospital for coronary artery bypass graft. Patients were randomized to receive either fibrinogen concentrate (n = 18) or placebo (n = 18). Hemoglobin, hematocrit, international normalized ratio, prothrombin time, partial thromboplastin time, and fibrinogen were checked preoperatively. The transfusion of allogeneic blood components and the volume of blood loss were recorded and compared between the groups.

Prophylactic fibrinogen injection reduced the need for blood transfusion, blood products, and postoperative hypotension in the fibrinogen groupwhencompared to the control group (P0.005). There was a significant difference between the two groups in terms of the amount of bleeding during operation (P0.005).

Fibrinogen plays a key role in preventing and stopping the bleeding. Accordingly, fibrinogen decreases bleeding and the need for paced cell in patients in CABG. Given the adverse outcomes of bleeding and coagulopathy in patients undergoing surgery, we conclude that the use of fibrinogen could be beneficial as a prophylactic in hemorrhagic surgery.

Choosing a proper approach to subclavian vein cannulation is a challenge for physicians. However, percutaneous infraclavicular subclavian vein cannulation is now an acceptable technique.

The present study was performed to compare the success rate and complications of subclavian vein cannulation using the midpoint technique and the lateral technique.

In this prospectiverandomizedclinical trial,werandomlyassigned440patientsundergoing subclavian vein cannulation to either midpoint approach or lateral approach groups from April 2018 to February 2019. The complications and success rates of catheterization were compared between the two approaches. The data were analyzed using SPSS software (version 20).

Unlike the first attempt of catheterization, the success rate was significantly higher in the midpoint technique (75 %) than in lateral technique (39%) in the second attempt (P = 0.003). The overall success rates were 96.8% and88.6% in the midpoint approach and lateral approach, respectively. A significant difference was observed between the two techniques in the overall success rate (P = 0.001). Inadvertent subclavian artery puncture occurred in 26 (5.9%) patients including 3 (1.4%) patients in the midpoint technique and 23 (10.5%) patients in the lateral technique. In 19 (4.3%) patients, malposition of the catheter tip occurred, including 14 (6.4%) in the midpoint approach and 5 (2.3%) in the lateral approach. There was a significant difference between the two approaches in malposition and subclavian artery puncture (P = 0.035 and P = 0.0001, respectively). There were no significant differences between the two techniques in other complications.

This investigation showed that the midpoint approach was more appropriate than the lateral approach for infraclavicular subclavian vein catheterization with landmark-based techniques.

Acute postoperative pain causes severe discomfort in patients accompanied by hemodynamic and metabolic instability.

Theaimof this study was to evaluate the effects of nitroglycerin additiononthe infusion of intravenous analgesiapump in patients with lower limb orthopedic surgery.

This study was a double-blind clinical trial conducted on 75 patients with lower limb fracture. Patients were randomly assigned to receive three regimens for postoperative pain control via intravenous analgesia pump, including group A (fentanyl 10mc/kg + 10 mL distilled water), B (fentanyl 10 mc/kg + nitroglycerin 500 mc), and C (fentanyl 10 mc/kg + nitroglycerin 1000 mc). The patients at the beginning of recovery and prior to putting the pain pump at the time of 4, 8, 12, 24, and 48 hours, were assessed with visual analogue scale (VAS) to measure pain and Ramsay scale to measure sedation.

The results showed that weight, height, and gender distribution were not significantly different in the three groups. The HR,MAP, and VASmeanscores showed a significant difference for intragroup and intergroup differences in the three groups atmany times.

Low dose nitroglycerine, as an adjuvant drug, can be added to intravenous patient-controlled analgesia pump in patients undergoing surgery for better analgesic purposes in patients without underlining disease.

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic method for treatment of many biliary diseases. With respect to rapid recovery and more patient comfort, this procedure is currently performed under light general anesthesia (GA) or conscious sedation.

The current study aimed to clarify that intravenous sedation or light general anesthesia can be performed without great fear of anesthesia related complications in ERCP patients and sedative doses of propofol can be used safely in outpatient settings under the supervision of an expert anesthesiologist.

This is a cross-sectional study on 1023 ERCP patients under light GA during 2014 - 2018 in Qom, Shahid Beheshti Hospital. Data were collected by a checklist and were analyzed by using chi-square test in SPSS V.22.

From 1023 patients, 501 (48.97 %) were male and 522 (51.03 %) were female with a mean age of 47.2  6.7 years. The most common finding in ERCP was choledocholithiasis (76.15 %). The most common complication was hemodynamic instability (37.01 %) followed by desaturation (11.65 %) both of them ware anesthesia related. Prevalence of GI (gastrointestinal) related complications was 13.39 %. The mostcommonGI related complications were pancreatitis (7.92 %) and bleeding (3.32 %). Total mortality rate was 0.88 %.

ERCP-related complications are inevitable but can be controlled by early diagnosis and clinical experience. Severe complications and high risk patients may increase the mortality and morbidity of the procedure. Anesthesia related complications are more frequent than GI related unwanted events. Fortunately, the most common anesthesia related complications are readily manageable and are minor in nature when an expert anesthesiologist is present in the scene. Close monitoring of the patient’s vital signs should be the mainstay of the safe procedure.