Anesthesiology and Pain Medicine
Volume:10 Issue: 2, Apr 2020

Spinal anesthesia is the most preferred method for cesarean section. This meta-analysis was performed to determine the effect of minimum and maximum intrathecal doses of meperidine (pethidine) [5 to 40 mg] on the maternal and newborn outcomes after cesarean section. Evidence Acquisition: The data were collected through the systematic search in the ISI, PubMed, Scopus, Google Scholar, Barakat, MagIran, SID, Irandoc, and EMBASE medical databases. Eighteen clinical trial studies with 1,494 patients were included.

Patients who had received intrathecal meperidine had experienced lower shivering, relative risk [RR] = 0.34 (95% CI = 0.23, 0.48) and longer analgesia, [standard mean difference (SMD)] = 7.67 (95% CI = 1.85, 13.49) after the surgery. Moreover, RR of nausea = 1.37 (95% CI = 1.13, 1.66), vomiting RR = 2.02 (95% CI = 1.28, 3.20), and pruritus RR = 9.26 (95% CI = 4.17, 20.58) was higher in the pethidine group than in the control group. There was no statistically significant difference in the Apgar score at one-minute RR = 0.99 (95% CI = 0.9, 1.09), at five-minute RR = 0.93 (95% CI = 0.87, 1.08), maternal hypotension RR = 1.00 (95% CI = 0.87, 1.15), and maternal sensory and motor blockade durations, SMD = -1.72 (95% CI = -3.78.0.34) and SMD = -4.38 (95% CI = -9.19, 0.44), respectively in the two pethidine and control groups.

Intrathecal meperidine can reduce shivering and increase the duration of postoperative analgesia, though it increases the relative risk of nausea, vomiting, and pruritus. No significant difference was found both in the Apgar score, maternal hypotension, and duration of the motor and sensory block.

The emergence of a novel coronavirus and coronavirus disease 2019 (COVID-19) represents a challenge to global healthcare. In the past 20 years, this is the third coronavirus that jumped the species barrier and infected humans. It is highly contagious but associated with low pathogenicity. First identified in Wuhan, China, a city of over 11 million, the disease has since spread to every continent except Antarctica. About 15% to 20% of all cases may be called severe, and it is believed many cases are asymptomatic. The average age of a person with COVID has been reported as 49 years. Worse outcomes are associated with geriatric populations and those with underlying diseases such as cardiovascular, respiratory disorders, and/or diabetes. The coronavirus, like other coronaviruses, is highly contagious and has a latency period of about 14 days. Most patients present with fever and a dry cough, but fever may be absent. Differential diagnosis can be challenging since influenza may present with similar symptoms. Chest radiography or computed tomography may be used to find evidence of secondary pneumonia. Nosocomial infection is of concern, and it has been reported that 3.8% of all cases with COVID-19 in that country involve healthcare workers in China. Most patients have mild disease, and supportive care suffices. A variety of repurposed and investigational drugs are being evaluated. There are currently no antiviral therapies or vaccines, even if many therapies are proposed. Hand hygiene, social distancing, and scientifically sound information are the best strategies at the moment to combat this epidemic.

During gynecologic laparoscopy, pneumoperitoneum, and the position of the patient's head can lead to pathophysiologic changes in cardiovascular and respiratory systems, complicating the management of anesthesia in these patients. One of the strategies for improving the respiratory status of patients undergoing laparoscopy is the use of Positive End-Expiratory Pressure (PEEP).

This study aimed to evaluate the effect of different levels of PEEP on the respiratory status of patients undergoing gynecologic laparoscopy.

In this clinical trial, 60 patients with ASA I were randomly assigned to three groups to control anesthesia: ZEEP (PEEP 0 cmH2O; 20 cases), PEEP5 (PEEP 5 cmH2O; 20 cases), and PEEP10 (PEEP 10 cmH2O; 20 cases). Respiratory and hemodynamic variables of patients were compared before general anesthetic induction and immediately after CO2 insufflation at intervals of 5, 10, 20, 30, and 60 min and the end of the operation in the three study groups.

The PEEP application improved pH, PaCO2, and PaO2 levels at the end of pneumoperitoneum compared to baseline when compared with the non-use of PEEP (ZEEP group). Also, the frequency of dysrhythmia in the use of PEEP in controlled ventilation was significantly lower in patients with PEEP10 (P < 0.05). The application of PEEP5 resulted in similar effects to PEEP10 in the levels of respiratory variables.

The PEEP application is associated with improved arterial blood gas in patients with gynecologic laparoscopy. The use of PEEP10 has a greater effect on the improvement of respiratory parameters and complications of pneumoperitoneum.

The toxic effect of local anesthesia on the retina has been previously investigated in animal studies but not in humans.

The objective of this study was to clarify the effect of local anesthesia with lidocaine versus local anesthesia with lidocaine with extra administration of adrenaline on the retinal layer thickness measured by optical coherence tomography (OCT) in patients indicated for elective cataract surgery.

This is a randomized controlled trial conducted on 60 patients indicated for elective cataract surgery under local anesthesia with lidocaine. Thirty participants received local anesthesia with lidocaine 2% with extra administration of adrenaline (adrenaline group), and 30 participants received local anesthesia with lidocaine 2% only (control group). The retinal thickness was measured for all participants preoperatively and one week postoperatively using OCT.

The OCT findings showed statistically significant decreases postoperatively in superior (P value = 0.028), inferior (P value = 0.017), and average (P value = 0.021) retinal thickness in the adrenaline group. Moreover, there were statistically significant decreases postoperatively in superior (P value = 0.032), inferior (P value = 0.046), and average (P value = 0.028) retinal thickness in the control group. Comparing the adrenaline and control groups for the OCT findings, there was no statistically significant difference between the groups regarding the decreases in superior (P value = 0.325), inferior (P value = 0.642), and average (P value = 0.291) retinal thickness.

Local anesthesia with lidocaine significantly decreased the retinal thickness. The extra administration of adrenaline to lidocaine did not affect the post-anesthetic changes in the retinal thickness.

Several behavioral tests have been devised to assess pain in rodent models, one of which is the Chronic constriction injury (CCI) model of the sciatic nerve, including the sensitivity of the paw evaluated through reflex reactions to heat or mechanical stimuli. However, because of their high restless activity and responsiveness to humans, it is tough to give the moving animals consistent stimuli to get consistent and reliable reactions.

Experiments were performed on male C57BL/6J mice (aged eight weeks) and prairie voles (aged eight weeks). Sham animals (five mice and six prairie voles) and CCI animals (six mice and seven prairie voles) were tested before surgery, four days after, and seven days after surgery. Each animal was rated using a modified rating scale for the scoring of nociceptive behavior. The mechanical threshold test was administered by applying arterial clips to the base of toes under isoflurane-induced sedation.

The right hind paw of the CCI administered side showed significant increases in the scores of nociceptive behavior on day 4 and day 7. The right hind paw of the CCI-administered side showed significant reductions in the mechanical threshold test on day 4 and day 7.

The results of the mechanical threshold test were consistent with those of the scoring of nociceptive behavior in CCI model animals, and the method of using arterial clips under sedation was useful for the mechanical threshold test.

Acute kidney injury (AKI) is one of the serious complications of cardiac surgery. It is worsened when accompanied by low cardiac output syndrome.

In this study, we compared kidney function based on the KDIGO criteria in isolated on-pump and off-pump coronary artery bypass graft (CABG) surgery.

In this cohort study, 52 patients with LCOS were enrolled after on-pump (28 patients) and off-pump (24 patients) CABG. In the first six hours after ICU entrance, blood samples were taken for serum creatinine based on routine. For determining AKI after surgery, we used the KDIGO criteria as a primary endpoint. Also, some clinical parameters were recorded before, during, and after surgery. The data were analyzed by SPSS software, version 24, using paired and independent t-test, ANOVA, and Pearson correlation test and non-parametric tests such as Mann-Whitney and Kruskal-Wallis tests at a significance level of P < 0.05.

There was no significant difference in age (P = 0.3) and gender (P = 0.57) between the two groups. Among cardiac disease risk factors, only hypertension (P = 0.02) had a significant difference between the two groups, but AKI in patients with hypertension did not show a significant difference (P = 0.09). In paraclinical parameters, serum creatinine showed a significant difference before and after surgery in on-pump (P < 0.001) and off-pump (P = 0.007) groups. Also, this parameter had a significant difference at 6 h, 12 h, 24 h, and 48 h after surgery between the on-pump and on-pump groups. The AKI incidence showed a significant difference between the two groups (P < 0.001).

The incidence of AKI was more in on-pump patients than in off-pump patients. Also, a significant difference was observed between their clinical parameters. Thus, to improve the patients’ clinical outcomes and lower the health costs, we suggest that patients with a high risk of LCOS be followed up after CABG, especially on-pump CABG.

The labor pain is one of the factors encouraging pregnant women for cesarean section delivery. Recently, intradermal and subdermal injection of distilled water has shown to be effective in improving this pain.

The present study aimed to determine which method has a greater impact on labor pain reduction.

In this double-blind, randomized clinical trial, 121 nulliparous women with a gestational age of ≥ 37 weeks were randomly divided into three groups: (1) 0.5 cc sterile water injection subdermally at four sacral points with insulin needles (n = 40); (2) 0.5 cc sterile water injection intradermally (n = 39); and (3) needle contact with the mentioned points as the placebo (n = 42). Before the intervention, the VAS score was measured for labor pain, and it was repeated 10, 30, 60, and 90 min after the intervention. The results were compared between the three groups.

Before the intervention, the mean VAS pain score had no significant difference between the three groups. However, 30, 60, and 90 min after the intervention, the mean pain score was significantly lower in the intradermal and subdermal injection groups than in the control group (P = 0.001); however, the difference between the intradermal and subdermal injection groups was not significant.

The injection of distilled water by either intradermal or subdermal method was associated with a significant reduction in the pain score during labor, but there was no difference between these two methods in terms of decreasing labor pain. As sterile water injection is a safe, effective, and low-cost method, it is proposed to increase the knowledge of midwives and obstetricians about this method.

 Pain is one of the main complaints of many patients in intensive care units. However, most nurses and physicians are unable to properly monitor and relieve pain in these patients. Factors such as patients' inability to describe their pain and insufficient knowledge of nurses and physicians have made pain management difficult. Given that the knowledge and attitude of nurses play an important role in the effective implementation of the pain management process, this study aimed to investigate the effect of comprehensive pain management training program on the awareness and attitude of intensive care unit nurses.

 This quasi-experimental single-group study was conducted in two phases (pre and post-intervention) to investigate the awareness and attitude of all nurses employed in the intensive care unit of Tehran Modarres Hospital, based on the determined inclusion and exclusion criteria. In the pre-intervention phase, the awareness and attitudes of the nurses were assessed using a questionnaire. After conducting the pain management training course, an executive program and algorithm were implemented for pain management in ICUs. Then, the nurses’ awareness and attitude toward pain management were assessed again. Finally, changes in the scores of the nurses’ awareness and attitude were analyzed by SPSS V. 22 software in two phases before and after applying the interventions using the Wilcoxon test. The relationship between some demographic variables and the level of awareness and attitude of nurses was also investigated using the Kruskal-Wallis and Mann-Whitney tests.

 The results of this study indicated that the mean score of the nurses’ awareness was significantly different in pre- and post-intervention phases (P < 0.05). Despite an increase in the post-intervention mean score of the nurses’ attitude (71.03), no statistically significant change was observed. Additionally, among the demographic variables, there was only a significant relationship between the nurses' job experience in ICUs and their attitudes.

 Based on the results of this study, teaching and implementing a comprehensive program for pain management can play an effective role in promoting the nurses’ awareness. Therefore, it is proposed to use pain management models to improve the nurses' knowledge and attitude toward pain management in ICU patients.
 

Pulsed radiofrequency stimulation (PRF) of the greater and lesser occipital nerves (GON and LON) has neuromodulative and analgesic properties.

The aim of this study was to investigate whether the PRF of the occipital nerves can cause sedation.

This is an observational case series study in Pain Management Unit of Attikon University Hospital. Patients suffering from primary headaches were scheduled for PRF of occipital nerves following a standardized protocol. The Bispectral Index device was applied and recorded every minute throughout the procedure.

22 patients were studied. BIS values were lowered in all but three patients during GON stimulation, and in all patients during LON stimulation. Values of decline compared to baseline ranged between 0 - 23 (median 8.5) for GON and 1 - 27 (median 14) for LON, with LON decline being significantly lower.

PRF at the occipital nerves led to mild sedation in all patients. Further studies are required to investigate this effect and clarify the exact mode of action of pulsed radiofrequency.

National Board of Anesthesiology (NBA) pass rate is an important and critical step in clinical residency programs.

This study was designed to assess the relationship between an integrative educational intervention (IEI) and the relative annual pass rate (RAPR). RAPR is defined as ratio of NBA pass rate of Shahid Beheshti University of Medical Sciences (SBMU) to the NBA pass rate of all the anesthesiology residency programs across Iran.

In a descriptive-analytic retrospective study from 2012 to 2019, RAPR was calculated. IEI was implanted in the latter 4years period of this time interval includes: (1) individualized mentorship for residents by faculty members; (2) monthly in-training examination (ITE) in written; and (3) periodical mocked OSCE exam. Spearman’s correlation coefficient was used to assess correlation between integrative educational intervention and RAPR results. P value less than 0.05 was considered statistically significant.

There was a statistically significant relationship between “integrative educational intervention program” and the RAPR

Spearman’s correlation coefficient = 0.655 (P value = 0.039).

The IEI package of Anesthesiology Department, SBMU showed a significant relationship with improvements in successfulness for anesthesiology residents in the National Board Exam (RAPR trend). More prolonged studies could prevail further aspects of these interventions.

Shoulder pain is very frequent, especially in middle-aged male adults. Its treatment may be very problematic, mainly in patients who cannot rest and stop their work. At present, it is treated with analgesics, physiotherapy, infiltration of corticosteroids, and/or radiofrequency neuromodulation of the suprascapular nerve. This may be effective but not easy to do. Its efficacy is limited in time, especially because the approach to the nerve trunk may be problematic for its anatomical nature. Ultrasonography has helped, but it is not always completely helpful, due to the small dimension and the complexity of the anatomical structure. In this case report, we describe a more helpful approach to the nerve trunk using an endoscopic technique. The results are very promising. However, larger studies would be necessary to make clear its usefulness.

Several studies have demonstrated an association between chronic pain and impairment of cognitive capabilities. Since the number sense is one of the cognitive ability involved in the evaluation of pain intensity using some pain measurement tools, impairment of number sense may impact pain assessment. Therefore, the validity of number-based pain assessment tools should be re-evaluated.

This study aimed to determine whether number sense is altered in chronic and acute pain patients compared to healthy subjects.

Overall, 150 participants were recruited and divided into the three groups of controls, chronic and acute pain patients. Pain intensity was evaluated using numeric and verbal rating scales as pain assessment tools. Number sense was assessed using number naming, number marking, and line bisection tasks. Deviation from correct answers was measured for each task.

Patients with chronic pain (migraine headache) had higher pain intensity scores than acute pain subjects. Chronic pain patients showed significant deviation from the expected responses compared to controls in the line bisection task.

Chronic pain patients may have impaired number sense and may differently use number-based pain assessment tools in comparison with healthy individuals.

This study compared the efficacy and safety of minimal tourniquet pressure using either determined limb occlusion pressure (LOP) or estimated arterial occlusion pressure (AOP) for elective upper limb surgeries.

Forty patients undergone elective upper limb surgery under general hypotensive anesthesia were randomized into groups A and B, where tourniquet pressure was calculated using AOP estimation for group A and LOP determination for group B. AOP, LOP, the time needed to estimate the AOP and determine the LOP and set the tourniquet inflation pressure, tourniquet inflation pressure, initial and maximal systolic blood pressure, heart rate, intraoperative fentanyl requirement, arm circumference, and tourniquet time were recorded. Tourniquet performance was assessed, and signs of tourniquet-related complications were noticed.

Systolic arterial blood pressure was comparable between the groups. Less time was recorded for measuring AOP or LOP and set the minimal inflation pressure (in second) in group A than in group B (62 ± 2 for group A vs. 120 ± 3 for group B; P < 0.001). The estimated AOP in group A was significantly higher than the determined LOP in group B (118 ± 2 vs. 91 ± 2; P < 0.001). Tourniquet inflation pressures were not significantly different between the groups. Tourniquet performance was excellent or good in all patients in both groups.

Arterial occlusion pressure estimation or LOP determination methods to set the tourniquet inflation pressure with hypotensive anesthesia can provide effective minimal inflation pressure and satisfactory surgical field for upper extremity surgeries without tourniquet-related complications.