Anesthesiology and Pain Medicine
Volume:12 Issue: 3, Jun 2022

Shivering is one of the most common side effects after cesarean section (C-section) under spinal or epidural anesthesia. However, it is often not treated.

The aim of this study was to evaluate the effectiveness of intravenous dexmedetomidine (DEX) in the prevention of shivering after intrathecal anesthesia in women undergoing C-sections.

This double-blind, placebo-controlled clinical trial was conducted on 80 women candidates for elective C-sections under intrathecal anesthesia who were referred to Imam Khomeini Governmental Hospital in Ahvaz, Iran, during 2020 - 2021. Patients were randomly divided into two groups of intravenous DEX (group D; 0.5 µg/kg) and normal saline (control, group C) and received the medications after umbilical cord clamping. All patients were evaluated during and after surgery for hemodynamic changes, the incidence and severity of shivering based on Chu and Tsai, side effects (e.g., nausea, vomiting), and sedation level based on the Ramsey scale.

The incidence of shivering in group C was significantly higher than in group D (P = 0.003). Moreover, the severity of shivering on minutes 20, 30, and 45 in group C was significantly higher than in group D (P < 0.05). The mean sedation score during minutes 10 - 30 in group D was significantly higher than in group C (P < 0.05). Heart rate was not significantly different between the two groups (P < 0.05). Systolic and diastolic blood pressure were higher in group D than in group C (P < 0.05).

The administration of intravenous DEX effectively reduces the incidence and severity of shivering and provides appropriate sedation in patients undergoing C-sections, and it does not cause remarkable side effects.

 Bone metastasis (BM) is a frequent complication of cancer, representing the third most common site of secondary spread in solid cancers behind the lung and liver. Bone metastasis is found in up to 90% of prostate and breast cancer patients. They can cause significant complications, such as pathological fractures and paralysis of the spine, which decrease daily functioning and quality of life (QoL) and worsen prognosis. The growing life expectancy of cancer patients due to improvements in systemic therapies may further increase BM's eventuality and clinical burden in cancer patients.

Four physicians from five different specialties were interviewed and resumed the most relevant literature of the last 20 years focusing on pain treatment in BM patients.

Treatment for BM ideally involves various types of specialists and assessments. The disease status and patient background should be considered, requiring holistic care and expertise from various medical specialties.

Interventional, nuclear medicine, radiotherapy, and mini-invasive techniques can be safe and effective for relieving pain and modifying health-related QoL in BM patients.

Regardless of the cause, pulmonary hypertension can increase patient complications and mortality. This study compared the effect of nebulized versus intravenous (IV) milrinone on reducing pulmonary arterial pressure in patients with pulmonary hypertension candidates for open-cardiac surgery.

This double-blind, randomized clinical trial was performed on 32 patients undergoing elective on-pump cardiac surgery during January 2021-January 2022 in the Cardiac Operating Room of Golestan Hospital, Ahvaz, Iran. Patients were randomly divided into test groups nebulize milrinone (N = 16) and IV milrinone (N = 16). The medication was administered after the cross-clamp of the aorta opening. The outcome variables included hemodynamic data, cardiac output, cardiac index, stroke volume, mean arterial pressure (MAP), central venous pressure, mean pulmonary artery pressure (mPAP), systemic vascular resistance, pulmonary vascular resistance, MAP/mPAP ratio, time until extubation, duration of hospitalization in the Intensive Care Unit (ICU), and duration of hospital stay.

In the nebulized group, MAP and MAP/mPAP were significantly higher than in the IV milrinone group (P = 0.09 and P < 0.0001, respectively). The time of extubation (P = 0.001), duration of hospitalization in the ICU (P = 0.009), and duration of hospital stay (P = 0.026) in the nebulized milrinone group were significantly shorter than in the IV milrinone group.

Nebulized milrinone administration before weaning off cardiopulmonary bypass (CPB) can be accelerated and facilitate weaning off CPB. Moreover, despite maintaining MAP, nebulized milrinone significantly reduces mPAP. According to the results of this study, nebulized milrinone is recommended in patients undergoing cardiac surgery with pulmonary hypertension.

The incidence of tracheal stenosis is progressively increasing. A risk factor for developing this clinical condition is a history of prolonged endotracheal intubation. A transnasal humidified rapid insufflation ventilatory exchange, known as THRIVE, has gained importance in tracheal resection surgeries.

Herein, we describe the anesthetic management of two obstetric patients, a 19-year-old and 29-year-old patients, with a history of prolonged endotracheal intubation and a diagnosis of tracheal stenosis. The patients required the resection of the tracheal segment and end-to-end anastomosis. The anesthetic management focused on THRIVE using a high-flow nasal cannula.

This system proved to be a safe anesthetic technique for pregnant women and the fetus. Furthermore, it allowed surgeons to better visualize the surgical field without the risk of accidental injury to the endotracheal tube.

Context: 

Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. Tailored pain regimens have also evolved and allowed patients to feel minimal to no discomfort after robotic urologic surgery, allowing in parallel better surgical outcomes. This study aims to analyze the most current pain regimens in robotic urologic surgery and to evaluate the most current pain protocols and corresponding outcomes.

Evidence Acquisition:

 A literature review was performed of published manuscripts utilizing Pubmed and Google Scholar on pain protocols for patients undergoing robotic urologic surgery.

 Multimodal analgesia is gaining ground in robotic urologic surgery. Regional analgesia includes four major modalities: Neuroaxial analgesia, intercostal blocks, tranvsersus abdominis plane blocks, and paravertebral blocks. Each approach has a different injection site, region of analgesia coverage, and duration of coverage depending upon local anesthesia and/or adjuvant utilized with advantages and disadvantages that make each modality unique and efficacious.

 Robotic urologic surgery has offered the advantage of smaller incisions, faster recovery, less postoperative opioid consumption, and better surgical outcomes. Neuraxial, intercostal, transversus abdominis plane, and quadratus lumborum blocks are the best and most adopted approaches which offer optimal outcomes to patients.

The SARS-CoV-2 pandemic is one of the most significant challenges for healthcare providers, particularly in the critical care setting. The timing of intubation in COVID-19 patients seems to be challenging. Therefore, we aimed to investigate how it may have a survival benefit, and we determined which clinical characteristics were associated with outcomes.

This cross-sectional study was conducted in the Imam Khomeini Hospital Complex. We randomly selected patients admitted to intensive care units and, based on intubation status, categorized them into three subgroups (early, late, and not intubated). Early intubation is defined as intubation within 48 hours of ICU admission, and late intubation is defined as intubation after 48 hours of ICU admission.

Early-intubated patients were more likely to have dyspnea than late-intubated patients, and late-intubated patients had a higher mean heart rate than early-intubated patients. The neutrophil/lymphocyte ratio was significantly (P < 0.05) lower in not-intubated patients than in other patients. There was no difference in NLR between early- and late-intubated patients. Mean serum creatine phosphokinase and troponin I levels were higher in late-intubated patients than in early- and not-intubated patients. Early-intubated patients had a lower ROX index than late-intubated patients. Patients with higher scores of APACHE 2, respiratory rates, and neutrophil to lymphocyte ratio were more likely to be intubated. Increasing APACHE and SOFA scores were associated with decreased odds of survival.

There were no statistically significant differences in total mortality between early- and late-intubated patients. APACHE 2 scores, NLR, RR, and history of ischemic heart disease are some of the appropriate predictors of intubation. Higher respiratory rates (tachypnea) can be an indicator of early intubation. The ROX index is one of the most sensitive and capable tools for predicting intubation. Intubation status is a potent predictor of in-hospital mortality.

One of the conditions leading to hemolysis in patients with artificial metallic heart valves is valvular dysfunction. In case of symptomatic hemolysis, a blood transfusion may be needed along with standard treatments. Inattention to the differential diagnosis of hemolysis and making decisions based on causes that are more obvious can lead to incorrect approaches.

In this case report, we presented a case with a previously undiagnosed rare blood group (positive antibody anti-E, anti-c, anti-Kell), undergoing reoperation of mitral valve replacement (MVR), who developed severe hemolysis and subsequent acute renal failure secondary to incompatible blood transfusion and required hemodialysis.

In this patient, hemolysis was solely attributed to mitral valve dysfunction. By timely diagnosis of the subtype of her blood group and appropriate decision-making during surgery, adverse blood transfusion outcomes were prevented.

Because of some difficulties during face mask ventilation in unconscious patients, such as upper airway obstruction patients, we conducted this study to compare nasal and face mask ventilation during general anesthesia induction.

In this clinical trial study, 70 patients between 3 and 12 years old undergoing elective lower abdominal surgery with general anesthesia were randomly divided into two groups. After administration of induction agents, one group was ventilated with the face mask and 100% oxygenation in three minutes and the other with the nasal mask. The mean expiratory volume, airway pressure, end-tidal CO2 (EtCO2), blood oxygen saturation (SpO2), and hemodynamic factors were recorded and compared in the baseline, two minutes after mask ventilation, and five minutes after intubation.

The mean EtCO2 in the second minute after ventilation was significantly higher in the nasal mask group than in the face mask group (P = 0.04). However, in the fifth minute after intubation, there was no significant difference between the two groups (P = 0.31). Other factors related to ventilation did not significantly differ between the two groups.

It can be concluded that nasal mask ventilation is as effective as facial mask ventilation. The nasal mask can replace the face mask if there is difficult face mask ventilation or airway obstruction.