Anesthesiology and Pain Medicine
Volume:13 Issue: 6, Dec 2023

Thoracic segmental spinal anesthesia (SA) may be a good alternative to general anesthesia (GA) for abdominal operations and laparoscopic procedures, especially in high-risk patients.

The aim of this study was to investigate the safety and efficacy of thoracic segmental SA vs GA during abdominal operations and laparoscopic procedures.

This study was conducted at our university hospital and involved a total of 46 patients who underwent abdominal operations and laparoscopic procedures. The study period spanned from January 15, 2022, to October 15, 2022. Patients were divided into 2 groups: group 1 (n = 23) received standard GA, and group 2 (n = 23) received thoracic segmental SA. A combination of 10 mg of hyperbaric bupivacaine 0.5% and 25g of fentanyl was injected through the spinal needle. The epidural catheter was then threaded through the Tuohy needle after withdrawal of the spinal needle to keep only 4 cm up in the epidural space. Demographic data, both intra and postoperative hemodynamic parameters, were monitored. Postoperatively, pain in both groups was treated with intravenous (IV) morphine by patient controlled analgesia (PCA), PCA settings were 1 mg morphine/mL, no background infusion, bolus dose 2 mL and lockout interval 15 min. Postoperative, both resting VAS and VAS during cough were measured for all patients at fixed intervals, and all patients were followed up for postoperative complications.

No significant variation was found in demographic data. Intra and postoperative mean arterial pressure (MAP) and heart rate (HR) measurements were higher in group 1 than in group 2 but without a statistically significant difference (P < 0.029). Early postoperative VAS values and discharge time from the postanesthesia care unit (PACU) were significantly reduced in group 2 than in group 1 (P < 0.001). The number of patients asked for analgesia and total opioid consumption were substantially reduced in group 2 than in group 1. Also, the time of the first analgesia request and patient satisfaction were substantially greater in group 2 than in group 1.

Combined thoracic spinal/epidural block results in stable hemodynamics, longer postoperative analgesia with fewer side effects, and greater surgeon and patient satisfaction in patients undergoing abdominal operations and laparoscopic procedures.

 Obesity is a growing problem worldwide and can affect both the pharmacodynamics and pharmacokinetics of various drugs, including anesthetics, resulting in the under-or overdosing of certain drugs. There is no consensus on the ideal dosing regimen for obese populations.

 In this study, 2 weight-based dosing of propofol used for induction of anesthesia were compared in terms of the onset of action time, adequacy of anesthesia, and effects on hemodynamic indices (eg, heart rate [HR] and blood pressure).

 In this randomized, double-blind clinical trial, 40 patients with morbid obesity (MO) scheduled for bariatric surgery with body mass index (BMI) > 35, age 18 - 59 years, American Society of Anesthesiologists physical status (ASA-PS) II and III were randomly divided into 2 groups, using block randomization method, to receive 2 mg/kg of propofol for induction of anesthesia based on either fat-free mass (FFM) group or ideal body weight (IBW) group. The primary outcome was the time duration to reach the bispectral index (BIS) ≤ 60. Time to the disappearance of eyelash reflex, signs of inadequate anesthesia (ie, BIS > 60, straining during intubation, or eye-opening), requirements for additional doses, and hemodynamic indices (including HR and mean arterial pressure [MAP]) were also compared.

 The mean time to reach BIS ≤ 60 was 134.1 s in the FFM group and 148.7 s in the IBW group. This difference was not statistically significant (P = 0.334). The time of disappearance of eyelash reflex was also not significantly different between the study groups (P = 0.814). However, 2 patients in the FFM group and 8 patients in the IBW group showed signs of inadequate anesthesia and required additional doses. This difference was statistically significant (P = 0.032). Hemodynamic variables, before and 2 min after propofol induction dose administration were comparable between the study groups (P = 0.520, P = 0.327, P = 0.847, P = 0.516 for pre-intervention MAP, post-intervention MAP, pre-intervention HR, and post-intervention HR, respectively).

 Propofol dosing, based on FFM and IBW, for induction of anesthesia, provides comparable onset time of action and hemodynamic effects; however, in terms of the adequacy of anesthesia, the dosing based on FFM is more favorable compared to the dosing based on IBW.

 Colonoscopy is an invasive and short-term diagnostic-therapeutic method that is associated with significant pain, discomfort, and anxiety in patients. Thus, various sedation and analgesia methods are used to reduce these complications.

 This study compared the effect of dexmedetomidine versus intravenous lidocaine on colonoscopy candidates under sedation with propofol-fentanyl.

 This double-blind clinical trial was conducted on two groups of randomly divided patients (n = 60 each) referring to the colonoscopy unit of Imam Khomeini Hospital in Ahvaz, Iran. The first group was given 2% intravenous lidocaine with an initial dose of 1.5 mg/kg and a maintenance dose of 1 mg/kg/h, plus propofol 0.5 mg/kg and 1 µg/kg fentanyl. In contrast, the second group was given dexmedetomidine with an initial dose of 1 µg/kg and a maintenance dose of 0.5 µg/kg/h plus 0.5 mg/kg propofol and 1 µg/kg fentanyl. Hemodynamic changes, degree of sedation, and patients' pain were measured and recorded at certain intervals.

 No significant differences were observed between the dexmedetomidine and lidocaine groups regarding gender, age, and weight (P > 0.05), and the two groups were homogeneous in this regard. The two groups were significantly different with respect to their heart rate after sedation (from 5 to 20 minutes) (P < 0.05), which was lower in the group receiving dexmedetomidine. In terms of mean arterial blood pressure, no significant difference was found between the dexmedetomidine and lidocaine groups (P > 0.05). With respect to the pain score at the end of the procedure, the two groups were significantly different (P < 0.05), with the group receiving dexmedetomidine obtaining a lower score.

 Although the use of lidocaine and dexmedetomidine is associated with the least hemodynamic changes, dexmedetomidine can create more suitable and favorable conditions during and after colonoscopy by inducing a higher degree of sedation and more analgesia.

In the postoperative period, open total abdominal hysterectomy (TAH) surgeries induce considerable pain. Multimodal strategies are being used to alleviate pain.

This study aimed to examine the efficacy and safety of dexamethasone and dexmedetomidine as an adjuvant to levobupivacaine in ultrasound-guided transversus abdominis plane (TAP) blocks for postoperative pain in TAH patients.

Atotal of 72 patients withASAgrade Iandgrade IIwererandomlyandequally assigned totwogroups. After the completion of surgery with a subarachnoid block (SAB), patients in group 1 received a mixture of 20 mL of 0.25% levobupivacaine and 4 mg of dexamethasone on each side of the TAP block. Patients in group 2 received a mixture of 20 mL of 0.25% levobupivacaine and dexmedetomidine, with a total dose of 1 g/kg body weight evenly distributed bilaterally in the TAP block. Patients were evaluated for pain using the Visual Analog Scale (VAS), total tramadol consumption as rescue analgesia, time to first rescue analgesia, any adverse effects, and patient satisfaction.

When comparing VAS scores for pain assessment, we observed that the mean VAS score was initially comparable between the two groups for the first hour. However, at 6, 9, and 12 h, VAS scores were significantly lower in group 2. The mean total tramadol consumption was higher in group 1 than in group 2 (213.33 ± 44.08 vs 161.11 ± 37.93 mg, P-value 0.027). The time to the first rescue analgesia after the TAP block in the postoperative period was significantly longer in group 2 (47.5 ± 62.76 vs 77.22 ± 56.14 min, P-value 0.002). No significant side effects were noted, and a greater proportion of patients in group 2 expressed satisfaction with their overall pain treatment.

The addition of dexmedetomidine to levobupivacaine is superior to the addition of dexamethasone, as it prolongs the duration of the block in the dexmedetomidine group. However, the use of dexamethasone as an adjuvant is a good alternative option, particularly due to its lower cost and reduced incidence of adverse effects such as postoperative nausea and vomiting.

The sympatholytic property of dexmedetomidine (DEX) makes it suitable as a hypotensive drug during functional endoscopic sinus surgery (FESS); however, delayed emergence from anesthesia and high postoperative sedation have been reported.

Delayed emergence from anesthesia and high postoperative sedation are associated with a prolonged length of stay in the operating room and the postanesthesia care unit (PACU), which increases health care costs. This study aimed to overcome the negative impact of DEX on recovery by using aminophylline.

This randomized, double-blind, placebo-controlled study was conducted on 52 patients planned for elective FESS under general anesthesia with DEX infusion for controlled hypotension during surgery. Patients were equally divided into 2 groups. The aminophylline group received 4 mg/kg aminophylline diluted in 50 mL saline 0.9% over 30 minutes after positioning in a 20-degree reverse Trendelenburg position. The control group received 50 mL saline 0.9% with a similar volume and period as the aminophylline group.

The extubation time was significantly shorter in the aminophylline group (6.5 (5.25 - 7.75) minutes) than in the control group (9 (7.25 - 10) minutes) (P-value < 0.001). The PACU discharge time was significantly shorter in the aminophylline group (15 (10 - 20) minutes) compared to the control group (20 (15 - 28.75) minutes) (P-value = 0.036). Intraoperative heart rate and mean arterial pressure were nonsignificantly different between the 2 groups. Ramsay sedation score measurements at 15 min, 30 min, and 60 min after extubation were significantly lower in the aminophylline than in the control group (P-value < 0.05). Complications were nonsignificantly different between the 2 groups.

Intraoperative aminophylline infusion enhances the recovery of patients undergoing FESS under DEX hypotensive anesthesia without intraoperative hemodynamic alterations and decreases their postoperative sedation without significant postoperative side effects.

Pain control and stabilizing hemodynamic indices are serious medical challenges, especially in anesthesia. Laparoscopic surgery is increasing in the world, and cholecystectomy surgery is no exception.

This study investigated the effect of intravenous (IV) magnesium sulfate injection on intraoperative end-tidal CO2 (ETCO2) levels and postoperative pain in laparoscopic cholecystectomy.

This is a clinical trial. The sample size was calculated to be 64 people who were selected among the patients who were candidates for laparoscopic surgery by convenience sampling. They were randomly assigned to intervention and control groups. The intervention group received magnesium sulfate (50 mg/kg) and normal saline (100 mL) within 1 h. The control group only received normal saline (100 mL). Systolic and diastolic blood pressures, ETCO2 level, heart rate, arterial oxygen saturation, pain level, and narcotic analgesics in recovery were measured 2, 6, 12, and 24 h after surgery. The data were analyzed using 1-way analysis of variance (ANOVA) and repeated measures analysis.

The mean of systolic blood pressure and ETCO2 during recovery in the intervention group were less than the control group (P = 0.029andP = 0.015). In the intervention group, analgesic consumption in recoveryand6hafter surgery was less than the control group (P < 0.001). The mean pain score in the intervention group in recovery and 2, 6 (P < 0.001), and 12 h (P = 0.038) after surgery was significantly lower than the control group.

Magnesium sulfate can be a suitable and safe supplement to reduce pain after surgery and reduce the use of narcotics. The current conclusion should be investigated on a larger scale of patients, with extended monitoring for postoperative pain over a longer period of time.

Non-invasive ventilation (NIV) is amethodof oxygenation supply that eliminates the need for an endotracheal airway. Non-invasive ventilation failure is defined as the necessity for endotracheal intubation or death during the NIV trial.

This study aimed to identify the predictors and associated factors of NIV failure in coronavirus disease 2019 (COVID-19) patients admitted to an intensive care unit (ICU).

This retrospective, longitudinal cohort study utilized electronic medical records of COVID-19 patients admitted to the ICU. A total of 150 patients were included in the study. Patient demographics, medical history, laboratory tests, partial pressure of carbon dioxide (PCO2), oxygen saturation (SpO2), heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR score), and the ratio of oxygen saturation (ROX) index (the SpO2/fraction of inspired oxygen [FIO2] to respiratory rate [SF] ratio) were recorded. Non-invasive ventilation failure was determined based on the need for endotracheal intubation or cardiac-respiratory arrest while on NIV.

Of 150 patients, 55.3% were male (mean age: 55.9 years), with an NIV failure rate of 67.3%, a mortality rate of 66.7%, and 3.3% of patients requiring tracheostomy after NIV failure. The ROX index consistently decreased over time, and an increase in the HACOR score and PCO2 after 6 hours of commencing NIV were the predictors of NIV failure. Additionally, higher levels of lactate dehydrogenase, lower SF ratios, and higher APACHE scores upon ICU admission were significantly associated with NIV failure. Notably, the erythrocyte sedimentation rate (ESR) as an inflammatory index, SF ratio upon ICU admission, HACOR score, ROX index, and PCO2 after 12 hours were significant predictors of in-hospital mortality in patients receiving NIV.

The ROX index, HACOR scale, and PCO2 are significant predictors of both NIV failure and in-hospital mortality.

Bupivacaine hydrochloride is widely used as the primary drug for spinal anesthesia.

This research aimed to evaluate the intrathecal administration of both isobaric and hyperbaric bupivacaine (HB) in lower abdominal surgery.

A randomized, controlled, double-blind trial was conducted on 50 patients classified as American Society of Anesthesiologists (ASA) class I to II, scheduled for lower abdominal surgery under spinal anesthesia. The patients were allocated randomly into two groups of similar size. Group A (control group) received 20 mg HB 0.5% intrathecally. Group B (case group) received 10 mg HB 0.5% and 10 mg isobaric bupivacaine (IB) 0.5%.

There was a significant decline in heart rate and mean arterial pressure in Group A compared to Group B (P < 0.05). Group A had a significantly greater sensory level at 10 and 20 minutes than Group B (P = 0.008 and 0.006, respectively). Group A had an earlier duration in reaching Bromage 3 and the first need for analgesia, compared to group B (P = 0.001 and 0.003, respectively).

In lower abdominal surgery, the intrathecal administration of HB with IB increased hemodynamic stability and duration of both sensory and motor blockade but with slower recovery from anesthesia compared to HB alone.

Continuous advancements in ultrasound (US)-guided neuraxial and peripheral nerve blocks (PNB) have allowed the safe and successful use of these blocks as adjuvants to general anesthesia in pediatric patients.

This study was designed to compare the analgesic efficacy of 2 US-guided regional techniques, caudal epidural block (CEB) and subgluteal sciatic nerve block (SNB), in children with cerebral palsy (CP).

The current randomized comparative study was conducted on 30 patients with spastic CP aged 2-12 years who were scheduled for unilateral lower limb multilevel soft tissue corrective surgeries, randomly distributed using a computerized program into 2 equal groups. The CEB group received a US-guided caudal block, and the SNB group received a US subgluteal sciatic nerve block. The time to the first postoperative analgesia requirement (primary outcome), postoperative pain score, total postoperative analgesic consumption, and perioperative complications (secondary outcomes) were assessed in both groups.

The duration of postoperative analgesia was significantly longer in patients of the SNB (14.65 ± 3.08 h) than in the CEB group (5.93 ± 1.68 h). The postoperative pain scores recorded at 6th-12th h and the postoperative 24-h rescue analgesic consumption were significantly lower in the SNB compared to the CEB group.

Ultrasound-guided subgluteal sciatic nerve block is a safe and effective alternative to US-guided caudal analgesia in pediatric patients with spastic CP scheduled for lower limb surgeries, with longer postoperative analgesia and similar perioperative safety profiles.

Post-lumbar surgery syndrome (PLSS) refers to persistent or recurrent pain following spinal surgery with an unknown cause. It is commonly associated with epidural fibrosis (EF). Some studies suggest that epidural steroid injection (ESI) can effectively alleviate pain in PLSS, particularly when targeting the S1 nerve root using S1 transforaminal epidural steroid injection (S1-TFESI). A key factor in a successful block is accurately visualizing the first dorsal sacral foramen, and the needle’s destination is the dorsal S1 foramen. Although S1-TFESI is often performed under fluoroscopy through the transforaminal route, an alternative to reduce radiation exposure is ultrasound guidance. This study aimed to compare the efficacy of ultrasound-guided caudal epidural steroid injection (CESI) and S1-TFESI in PLSS patients.

Arandomized double-blinded clinical trial was conducted involving 52 PLSS patientswhowere randomly assigned to either the CESI group or the S1-TFESI group. The patients were positioned prone. A linear transducer with a curve at a low frequency (2 - 5 MHz) was used to visualize the area. An aseptically prepared puncture site was used to insert a 2- to 5-MHz curved ultrasound probe with an ultrasound gel to identify the articular processes of the lower lumbar vertebrae and the posterior sacral surface. The probe was then positioned longitudinally to the para-sacral area, about 2 cm lateral to the midline. The articular process represented the L5/S1 level at the farthest caudal side, and the S1 posterior sacral foramen was represented by the concavity at the posterior sacral surface that was somewhat caudal. The probe was angled caudally to provide enough room for the needle to enter the S1 foramen. The injection site for the needle tip was the S1 foramen. A combination of triamcinolone (40 mg, 1 mL), normal saline (2 mL), and ropivacaine (0.2%) was administered. For TFS1 ESI, 5 mL of the combination was used. For CESI, the sacral hiatus was palpated in the prone position, and a linear high-frequency transducer was placed transversely to obtain a transverse view of the sacral hiatus. A combination of triamcinolone 40 mg and ropivacaine (0.2%) totaling 10 mL was employed. The Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI) were used to assess patients’ preoperative and postoperative conditions, and adverse events were recorded. Follow-up was conducted one week and one month after the procedures.

In both groups, NRS and ODI scores decreased at different time points after treatment, compared to baseline (P< 0.001). The CESI group had lower median ODI scores after one week and one month, although this difference did not reach statistical significance (P = 0.334). Despite similar baseline NRS ratings, the CESI group had statistically significantly lower mean NRS scores at one week and one month (P< 0.001).

The current study demonstrated that both CESI and TFESI treatments for PLSS following lumbar discectomy are effective and safe. These procedures can alleviate pain and reduce disability. Although the success rates of the two procedures are comparable, CESI appears to be more successful in reducing pain at the one-week and one-month follow-up.

A laryngeal mask airway (LMA) is a simple and non-invasive device used to establish the airway and maintain ventilation and oxygenation during short-duration medical procedures.

This study aimed to compare the placement of an LMA using an innovative technique vs the classic method.

This clinical trial was conducted at Faiz Hospital in Isfahan. Out of 110 candidates for elective eye surgery, 10 patients were excluded from the study as they did not meet the inclusion criteria. Ultimately, 100 patients were randomly allocated to 2 groups of 50 each. One group underwent LMA insertion using the classic method, while the other group underwent insertion using the face-to-face triple maneuver technique (FFTMT). Data, including laryngeal mask insertion conditions, hemodynamic responses, and clinical complications, were collected, entered into SPSS version 26, and analyzed.

There were no significant differences between the 2 groups in terms of laryngeal mask placement time (P = 0.061), number of attempts to place the LMA (P = 0.059), oropharyngeal leak pressure (OLP; P = 0.942), frequency of hoarseness (P > 0.99), or laryngospasm (P > 0.99). However, it is noteworthy that FFTMT appeared to provide easier placement of the LMA (P < 0.0001), required fewer attempts, and offered better quality of ventilation with a lower presence of blood on the cuff (P = 0.038). Conversely, the FFTMT group had a higher frequency of sore throat (P < 0.0001).

The performance of LMA using FFTMT is comparable to the classic method. In procedures under general anesthesia where the surgeon has access to the patient’s head and neck (such as cataract surgery), airway management with LMA using FFTMT (while maintaining the patient’s sterile covering) appears to be effective in case of an emergency.

 Tracheal intubation is a common technique used to secure a patient’s airway, which is crucial in anesthesia. Successful tracheal intubation depends on various factors, including the assessment of the patient’s airway before the procedure. In recent years, scoring systems, such as LEMON (an acronym for the assessment of the airway’s appearance, identification of any dental issues, evaluation of Mallampati classification, assessment of airway obstruction, and examination of neck mobility) and intubation difficulty scale (IDS) have gained attention. This study aimed to investigate the relationship between the LEMON criteria and IDS in tracheal intubation. The goal was to provide valuable insights that can assist medical professionals in optimizing their approach to airway management by analyzing clinical data, assessing patient outcomes, and evaluating the consistency between these scoring systems.

 This study was based on a descriptive-analytical study involving a group of patients requiring intubation. This study examined 105 patients scheduled for elective surgeries, aged between 19 and 60 years, without specific underlying diseases, such as laryngeal cancer, temporomandibular joint stiffness, or significant tongue enlargement, and with a body mass index (BMI) below 40 kg/m². Initially, expert anesthesiologists assessed the patients using the LEMON criteria, and then the degree of intubation difficulty was measured using the IDS scoring system. Finally, these two criteria were compared.

 In this study, there was a significant correlation between the LEMON score and the IDS score (P < 0.001). The difficult intubation group (IDS score higher than 0) had higher LEMON scores (with the highest score equal to 4) than the non-difficult intubation group (IDS score of 0) (P = 0.017). The average LEMON and IDS scores were 3.11 and 1.35, respectively. Among the participants, 96.2% had an intubation difficulty score of ≤ 5; nevertheless, 3.8% had a score of > 5. Additionally, limited neck mobility emerged as the sole independent predictor of intubation difficulty (P = 0.002, odds ratio = 6.152).

 The LEMON score is associated with difficult intubation in adult patients requiring intubation.

Herpes zoster (HZ), also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV). There have been several reports of HZ associated with COVID-19 vaccination, and the outcomes have varied.

In this report, we present 4 cases of patients who experienced HZ reactivation after receiving a COVID-19 vaccine. These individuals sought treatment at a pain management center due to postherpetic neuralgia (PHN). While HZ itself can be treated, post-herpetic neuralgia can persist for years, significantly impacting the patients’ quality of life. Therefore, early recognition of this adverse effect is crucial, and patients should receive specialized analgesic support promptly to prevent the development of chronic pain.

PHACES syndrome is a neurocutaneous syndrome that consists of posterior fossa brain malformation, hemangiomas of the face, arterial cerebrovascular malformation, cardiovascular anomalies (Coarctation of the aorta), eye anomaly, and sternal defect or supraumbilical raphe. Most of these manifestations would interfere with anesthesia and hence need major considerations.

A 2.5-month-old female weighing 2100 gr was a candidate for laser therapy due to retinopathy of prematurity. She was diagnosed with PHACES syndrome. Her anesthesia was induced and maintained with sevoflurane. LMA #1 was used for airway management. No complications occurred during or after anesthesia, and she was discharged the next day.

PHACES syndrome interacts with numerous anesthesia-related characteristics, such as airway management, cardiovascular disease, and CNS malformations. Based on the accompanying characteristics, perioperative care for these patients should be tailored.