Anesthesiology and Pain Medicine
Volume:13 Issue: 3, Jun 2023

Context: 

The type of anesthesia in cesarean section can affect the mother and baby. This study aimed to determine the comparative effect of intrathecal hyperbaric bupivacaine vs. hyperbaric ropivacaine on maternal and neonatal outcomes after cesarean section.

Evidence Acquisition:

 PubMed, Web of Science, Embase, Google Scholar, IranDoc, MagIran, and Scopus databases were searched from 1 September 2022 to 1 November 2022. Eighteen clinical trials with 1542 patients were included in the analysis.

There was no statistically significant difference in hypotension, bradycardia, and Apgar score between the 2 groups (P > 0.05). The risk of nausea (relative risk (RR), 1.526; 95% CI, 1.175 - 1.981; P = 0.001) and vomiting (RR, 1.542; 95% CI, 1.048 - 2.268; P = 0.02) caused by bupivacaine was 0.53% and 0.54% higher than that of ropivacaine. The incidence of shivering (RR, 2.24; 95% CI, 1.480 - 3.39; P = 0.00) was 2.24 times higher in the bupivacaine group than in the ropivacaine group. The average onset time of sensory block (standardized mean difference (SMD), -0.550; 95% CI, -1.054 to -0.045; P = 0.032) and motor block (SMD, -0.812; 95% CI, -1.254 to -0.371; P = 0.000) was significantly lower in the bupivacaine group than in the ropivacaine group.

Despite the fact that ropivacaine and bupivacaine are effective in cesarean section, ropivacaine is more favorable because of lesshemodynamicchanges, less duration of sensoryandmotorblock, andfewer side effects, whichare effective in patient recovery.

Context:

 Hemiplegic shoulder pain (HSP) is one of the complications of a stroke.

This study aimed to determine shoulder pain prevalence in cerebrovascular accident (CVA) patients.

This meta-analysis study searched English and Persian descriptive or descriptive-analytical full-text studies on CVA patients. The search was carried out in all databases by two researchers using keywords such as stroke, pain, CVA, hemiplegic, and shoulder pain. Data analysis was done with the software CMA3.

In the initial search, 109 articles were found, and finally, the data from four articles were analyzed. The prevalence of HSP was 23% (confidence interval (CI) = 10.3% - 43.5%).

Considering the HSP prevalence (28.1%) among CVA patients, it is necessary to carry out rehabilitation interventions to prevent such pain in these patients. It is also suggested that rehabilitation interventions be included in the patient education of the healthcare system.

Context: 

After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO).

In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline.

We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation.

Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 g/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 g/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval.

The limitation of this review is that it necessarily covers a broad range of ECMOdecisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.

Parkinson’s disease (PD) is a chronic neurological degenerative disease affecting the central nervous system, which is responsible for progressive disorders such as slow movements, tremors, rigidity, and cognitive disorders. There are no specific recommendations and guidelines for anesthetic management of patients with PD undergoing ophthalmic procedures. This narrative review aims to summarise the anesthetic considerations in patients with PD presenting for cataract surgery.

Intravenous cannulation is a prerequisite before any major or minor surgical procedures.

The rationale of the study was to compare the effectiveness of eutectic mixtures of local anesthetics (EMLA) cream and vapocoolant spray for pain reduction during intravenous (I.V.) cannulation.

This observational prospective cohort study was done on 140 patients requiring I.V. cannulation prior to elective procedure who were divided into two groups, including group E: EMLA (eutectic mixtures of local anesthetics) cream and group V: Vapocoolant spray (ethyl chloride). Visual Analogue Scale (VAS) score, hemodynamic variables, and cost analysis were studied between the two groups. Statistical analyses were done using Mann-Whitney U test, unpaired t-test, Fisher’s exact test, and chi-square test were used to identify variation in pain scores between the two groups. Post hoc analysis was done at different time points by the Bonferroni test. P-value < 0.05 was considered statistically significant.

It was observed that the groups were comparable in terms of age, sex, and American Society of Anesthesiologists (ASA) physical status. A highly significant difference was observed between the two groups in terms of VAS scores for pain. There was also a significant difference in terms of heart rate and movement of hands during cannulation between the two groups. No changes were observed in the other hemodynamic parameters. Vapocoolant spray was also more cost-effective compared to EMLA cream with an occlusive dressing.

Vapocoolant spray was a better tool compared to EMLA cream for intravenous cannulation, especially in emergency settings.

 The occurrence of lung ultrasound abnormalities in patients without lung disease remains uncertain, while patients with respiratory disease often exhibit such abnormalities.

 The primary aim was to identify pathological ultrasonographic pulmonary findings and their correlation with baseline diseases and static lung compliance in patients without any pre-existing respiratory conditions.

 This prospective observational study enrolled a series of surgical patients with no history of pulmonary pathology (n = 104). Baseline diseases and patients' physical status classification, based on the American Society of Anesthesiologists (ASA), were documented by reviewing medical records. Prior to surgery, a lung ultrasound was performed to assess pulmonary changes. During surgery with general anesthesia, static lung compliance was measured. The Spearman correlation coefficient was employed to determine the correlation between the two variables.

 Twenty-four patients (23.07%) exhibited 1 - 2 B-lines in certain lung fields. Seven patients (6.7%) had an ultrasound B-line score > 0 (indicating ≥ 3 B-lines). Among these patients, the average number of lung fields with ≥ 3 B-lines was 3.71 ± 2.43. Patients with systemic diseases (ASA ≥ 2) displayed a higher number of B-lines compared to ASA I patients (P-value = 0.039). Pleural irregularities were found in 10 patients (9.6%), while atelectasis and pleural effusion were observed in five (4.8%) and four (3.8%) patients, respectively. The mean lung compliance value was 56.78 ± 15.33. No correlation was observed between the total score of the B-lines and lung compliance (Spearman's correlation: rho = -0.028, P-value = 0.812).

 Patients without pulmonary pathology may exhibit ultrasound pulmonary abnormalities, which tend to increase with higher ASA scores and do not appear to have a correlation with static lung compliance.

Laryngoscopy is the most painful noxious stimulus during anesthesia and surgery. Dexmedetomidine is increasingly used as a sedative in surgeries involving microlaryngoscopy.

This study aimed to evaluate the effect of dexmedetomidine and a combination of fentanyl and midazolam on mitigating the stress response in patients scheduled for microlaryngoscopy.

This randomized, double-blind clinical trial enrolled 60 patients (28 males and 32 females) aged 18 - 65 years with the American Society of Anesthesiologists (ASA) physical status I - III. The patients were scheduled for microlaryngoscopy and equally divided into 2 groups. Group D received 1 g/kg of dexmedetomidine and saline bolus dose over 10 minutes before general anesthesia (GA) induction, followed by 0.5 g/kg/h of dexmedetomidine and saline infusions after GA induction. Group MF received 0.8 g/kg of fentanyl plus 0.05 mg/kg of midazolam over 10 minutes before GA induction, followed by 1 g/kg/h of fentanyl plus 0.05 mg/kg/h of midazolam as an infusion. The heart rate (HR) and mean arterial blood pressure (MAP) pressure were recorded from baseline until the end of surgery. Infusions were stopped at the end of the surgery.

The number of patients requiring propofol and intraoperative supplemental propofol was significantly lower in group D than in group MF. The heart rate was significantly lower in group D than in group MF (P = 0.022, 0.048, 0.032, 0.045, 0.041, 0.026, 0.030, and 0.036) from induction until the end of surgery; in addition, it was comparable between both groups at baseline and before induction. MAP was comparable between both groups for all measurements.

Dexmedetomidine mitigates the hemodynamic changes related to microlaryngoscopy more effectively than the fentanyl-midazolam combination.

Despite the high acceptability of the extracorporeal shock wave lithotripsy (ESWL) procedure in the treatment of urinary stones at all ages, it is necessary to use a variety of analgesic drugs during the procedure, especially among children.

We aimed to evaluate the effect of dexmedetomidine-ketamine (DK) and midazolam-ketamine (MK) compounds in the sedation of children (2-6 years old) undergoing ESWL.

This randomized, double-blind clinical trial was performed on children aged 2 to 6 years with renal stones undergoing ESWL. The participants were randomly assigned to the DK and MK regimen groups (dexmedetomidine, 0.05 mcg/kg within 10 minutes infusion; midazolam, 0.05 mg/kg within 3 minutes infusion; ketamine, 0.5 mg/kg bolus injection). The patients were assessed with respect to sedation degree, post-procedure hemodynamic status, recovery time and awakening, and operator satisfaction.

Recovery time was significantly shorter in the DK group than in the MK group. Also, the DK regimen was more analgesic than the MK regimen; therefore, the need to repeat ketamine administration was less. There was no difference between the 2 methods in terms of cooperation at the time of separation of children from their parents, patient cooperation during the procedure, average verbal response time and average cooperation time after entering recovery, and operator satisfaction with the operation. No side effects were observed in the 2 groups.

Ketamine with dexmedetomidine is associated with greater analgesia and shorter recovery time; however, sedation time was longer (insignificant) in ketamine with midazolam than in ketamine with dexmedetomidine. Thus, ketamine with dexmedetomidine is more preferred.

Stroke is prevalent in Iran, and its complications can decline patients’ quality of life and psychological state.

This study aimed to investigate the relationship between pain following stroke (PFS) and disability in stroke patients.

The current case-control study was conducted on 184 stroke patients (92 cases and 92 controls). Data collection tools included a demographic questionnaire, the Visual Analog Scale (VAS), and the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire. Based on the medical files of all patients with stroke, eligible ones were invited to participate in the study via phone calls. The collected data were then analyzed.

The disability rate was higher in the case group of patients with a history of hemorrhagic stroke, smoking, stroke, and diabetes (P < 0.05). The mean ± SD age was 72.45 (11.54). Also, the level of disability in patients increased with age (P = 0.000). The mean ± SD disability score was 78.63 (6.92) in patients with PFS and 54.9 (10.87) in patients without PFS. Also, R = 0.795 and R2= 0.631 indicated the significance of disability severity in patients with PFS.

The prevalence of disability was higher in patients with higher PFS levels. Hence, drug interventions or rehabilitation programs can be used to reduce the disability of stroke patients.

Direct laryngoscopy is the standard method for intubation in pediatric patients. The introduction of video laryngoscopy brought a paradigm shift in managing pediatric airways.

We compared the tracheal intubation technique between direct and video laryngoscopy with McIntosh Blade 2 in pediatric patients 2 - 8 years of age requiring airway management. The glottic view and the first pass success rate were compared and analyzed.

An observational cross-sectional study was conducted with 120 children between 2 - 8 years with normal airways. They were divided into video laryngoscopy (Group V) and direct laryngoscopy (Group D). The primary outcome measures included time taken for intubation, number of attempts required, Cormack-Lehane glottic view, use of optimization maneuvers, the requirement of tube repositioning, and hemodynamic parameters before and after intubation.

The time taken for intubation was longer in the video laryngoscopy group (group D, 24.28 sec vs. group V, 27.65 seconds (P = 0.01). The Cormack-Lehane glottic view was grade 1 in all the patients in the video laryngoscopy group, while only 35 children showed grade 1 in the direct laryngoscopy group. (P< 0.001).We observed a significant increase in both heart rate andmeanarterial pressure in the video laryngoscopy group at 1, 3, 5, and 10 min after intubation (P < 0.001, P < 0.05).

The time taken for intubation was more in group V, but the glottic view was much better, and the requirement for external maneuvers was also less. Pressure response to intubation was more in group V compared to group D.

Opium has been used for thousands of years for medical and analgesic purposes, and its misuse has also increased in recent years. Methadone, a synthetic opioid, has been used as an analgesic and to help patients quit opium addiction. However, some evidence suggests that long-term use of opioids can affect the hypothalamic-pituitary-adrenal axis.

We aimed to evaluate the serum cortisol level and response to the cosyntropin stimulation test in opium addicts on methadone treatment.

The study was conducted in November 2019 at Imam Reza Hospital Rehab Center, Birjand, Iran. Thirty-eight methadonetreated opium addicts participated in the study. A blood sample was initially obtained, then 250 g intramuscular cosyntropin was injected. After 30 and 60 minutes, two other blood samples were obtained. The data were analyzed using SPSS.

There was a significant difference between serum cortisol levels and the normal value in methadone users (9.46 ± 5.42 vs. 14 g/dL) (P < 0.001). The mean response to the cosyntropin stimulation test in methadone users was 9.34 ± 8.11 g/dL. Also, 55% of the participants had adrenal insufficiency.

Serum cortisol levels significantly differed from normal values in methadone-treated patients. Therefore, we recommend measuring serum cortisol levels in methadone-treated patients before major medical procedures to consider the stress doses of corticosteroids.

Patientsmayexperience anxiety, discomfort, and pain during endoscopy, which cannot be tolerated without sedative drugs.

This study aimed to compare the sedative effects of dexmedetomidine and midazolam on patients undergoing endosonography outside the operating room.

This randomized, double-blind clinical trial was conducted on 126 patients aged 18 - 65 years old with American Society of Anesthesiologists (ASA) physical status I - II undergoing elective endosonography. Patients were randomly divided into 2 groups. The dexmedetomidine group received dexmedetomidine (1 g/kg) for 25 minutes with propofol (0.5 mg/kg) and fentanyl (1 g/kg) at the start of the procedure. The midazolam group received midazolam (0.03 mg/kg) with propofol (0.5 mg/kg) and fentanyl (1 g/kg). Heart rate, mean arterial pressure (MAP), and oxygen saturation (SpO2) were recorded before and 5, 10, and 15 minutes after starting the procedure. The Ramsay Sedation Scale (RSS) and the need for an additional dose of propofol were recorded during the procedure. The Numeric Pain Rating scale (Ambesh score) scores were recorded at the beginning, immediately after, and 1 hour after the procedure. Nausea and vomiting were assessed using the Visual Analogue Scale in cooperation with the patient.

The dexmedetomidine group had significantly higher SpO2 and RSS scores during sedation than the midazolam group (P = 0.02). Overall, specialist satisfaction was higher in the dexmedetomidine group than in the midazolam group. There was no clinically significant difference in pain score and nausea and vomiting frequencies between the 2 groups.

Dexmedetomidine is more effective than midazolam for sedation during gastrointestinal endosonography.

Schwartz-Jampel syndrome (SJS) is a rare autosomal recessive disease characterized by muscle weakness and stiffness, abnormal bone development, short stature, joint contractures, and facial dysmorphisms. Myopathy, anatomical deformities, and malignant hyperthermia are challenging for anesthesiologists.

This case report describes one case of SJS. The female patient was scheduled for Blepharoplasty in Rasuol Akram General Hospital.

These patients may have difficult intubation and be prone to malignant hyperthermia. We managed this patient by applying Rocuronium, propofol, and C-MAC video laryngoscopy.

Symptomatic patients with coronavirus disease 2019 (COVID-19) mostly have flu-like symptoms. However, neurologic manifestations are common and may be the early findings of COVID-19. Data for COVID-19 do not indicate an increased risk of infection in pregnant individuals, but the risk of disease severity and mortality is high in this patient population. We report a case of a pregnant woman in the 10th gestational week, who presented with neurological symptoms of sudden impairment in walking, balance, speech, and consciousness, started the night before, and a seven-day history of fever, chills, myalgia, and general weakness before admission. The polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive for the cerebrospinal fluid sample a day before the positive nasopharyngeal sample. Axial brain magnetic resonance imaging revealed the involvement of the spinothalamic tract. Following treatment with intravenous immunoglobulin, the patient’s neurological condition gradually recovered, except for lower limb muscle strength, and she was discharged from the hospital on the 10th day of admission. This case is unique as it emphasizes the importance of considering COVID-19 when uncommon neurologic manifestations with negative nasopharyngeal PCR are present.

The erector spinae plane (ESP) block is a regional anesthetic technique that involves injecting a local anesthetic below the erector spinae muscle in an interfascial plane.

We report a case of a 66-year-oldmanwith cervicothoracic junction pain caused byanadvanced Pancoasttumor. The administration of ESP block at the T2-T3 level led to pain relief of more than 50% in this patient after two sessions.

Therefore, the application of this method of regional analgesia is both convenient and safe and reduces opioid consumption. Further studies are needed to evaluate the safety and effectiveness of continuous blocks in outpatient settings.