فهرست مطالب

Anesthesiology and Pain Medicine - Volume:14 Issue: 2, Apr 2024

Anesthesiology and Pain Medicine
Volume:14 Issue: 2, Apr 2024

  • تاریخ انتشار: 1403/01/09
  • تعداد عناوین: 13
|
  • Shervin Shahinpour, Fatemeh Refahi, Nader Ali Nazemian * Page 1
    Background

     Post-spinal anesthesia back pain often initiates with needle insertion and may persist for months, particularly among young women following cesarean section. Mechanical vibration has been proposed as an effective method to alleviate this pain.

    Objectives

     The study aimed to evaluate the impact of vibration on reducing pain experienced during needle insertion, as well as its effects one week and one-month post-puncture.

    Methods

     This randomized clinical trial enrolled patients undergoing spinal anesthesia for various surgical procedures. Patients were randomly assigned to either receive routine spinal anesthesia or spinal anesthesia combined with vibration. Demographic data were collected, and pain levels during needle insertion and back pain were assessed using a visual analog scale (VAS).

    Results

     A total of 64 patients were included in the study. There were no significant differences between the two groups in terms of the number of attempts required for needle insertion (P = 0.341), the predominant anatomical level, or the needle approach (midline or paramedian). Ultimately, pain experienced during needle insertion, back pain after one week, and back pain after one month did not differ significantly between the two groups (P = 0.562, P = 0.14, and P = 0.267, respectively)

    Conclusions

     The results of the present study showed that vibration at the site of needle insertion during spinal anesthesia had no effect on acute and chronic back pain on subsequent follow-up due to spinal anesthesia.

    Keywords: Spinal Anesthesia, Back Pain, Vibration
  • Hamidreza Shetabi, Darioush Moradi Farsani *, Zahra Allafchian Page 2
    Background

     Laryngoscopy and tracheal intubation lead to an increased sympathetic reflex response, which is associated with increased heart rate and blood pressure. This response can be detrimental in patients with myocardial ischemia. This study aimed to investigate the effects of etomidate in comparison to a combination of midazolam and sodium thiopental in reducing the sympathetic response to laryngoscopy and tracheal intubation.

    Methods

     This double-blind, randomized clinical trial study was conducted on two groups of 39 candidates for elective surgery under general anesthesia. Anesthesia was induced by etomidate (E) 0.3 mg/kg in the first group and sodium thiopental 2.5 mg/kg and midazolam 0.075 mg/kg in the second group (TM); then, the patients were intubated. Laryngoscopy findings and cardiovascular response were evaluated during the study. Finally, the data were analyzed using SPSS version 23 (IBM SPSS, Armonk, NY, USA).

    Results

     There was no significant difference between the two groups in terms of age (P = 0.82), weight (P = 0.42), height (P = 0.201), body mass index (P = 0.78), gender (P = 0.65), American Society of Anesthesiologists (ASA) physical status (P = 0.36), and laryngoscopy view grading (P = 0.83). The average laryngoscopy time in the E group was less than the TM group (P = 0.019). In the TM group, at 10 minutes after intubation, mean diastolic blood pressure (P = 0.029) and mean arterial blood pressure (P = 0.023) were significantly lower; however, at other times, there was no significant difference between the two groups (P > 0.05). There was no significant difference between the two groups in terms of adverse responses to laryngoscopy and intubation (P = 0.19).

    Conclusions

     The results of the present study showed that etomidate (E) and a combination of midazolam-sodium thiopental (TM) acted similarly in attenuating the cardiovascular response to laryngoscopy and tracheal intubation, and it seems that TM can be used instead of E if needed.

    Keywords: Cardiovascular, Etomidate, Laryngoscopy, Midazolam, Sodium Thiopental
  • Mahmoud Badry Ahmed *, DrAhmed Zaghloul, Ahmed Maarouf, Mohammed M Maarouf, Minatallah Elshafie Page 3
    Background

     Proper perioperative pain management remains a cornerstone of well-conducted functional endoscopic sinus surgery (FESS). In such a context, proper pain management entails the adequate provision of prolonged postoperative analgesia, the avoidance of overusing opioids, and consequently limiting their unwanted side effects.

    Objectives

     We aimed to evaluate the effect of bilateral ultrasound-guided suprazygomatic maxillary nerve block (MNB) on postoperative pain in patients undergoing FESS.

    Methods

     Patients eligible for FESS were randomized into two groups: the MNB group (n = 30), who underwent bilateral ultrasound-guided suprazygomatic maxillary nerve block after induction of anesthesia, and a control group (n = 30), who received multimodal analgesia, including opioids. Postoperatively, patients were observed for 48 hours. Pain scores were evaluated upon arrival to the sPACU and at 2, 6, 12, 24, 36, and 48 hours postoperatively, particularly at the time of removal of the hemostatic agent after 36 hours postoperatively. Total rescue analgesia, postoperative complications (including nausea and vomiting [PONV], hypotension, bradycardia, headache), and patient satisfaction were also diligently recorded.

    Results

     Sixty patients who were candidates and underwent FESS surgery were enrolled randomly in both groups. The NRS pain score in the MNB group was significantly lower than that of the control group (P < 0.001), especially the NRS during the removal of the hemostatic agent at T10 was significantly lower in the MNB group (P < 0.001). However, at the 24 - hour point post-surgery, there were no significant differences between both groups (P = 0.568). Total rescue analgesia required was significantly lower in the MNB group compared with the control group (P < 0.001) throughout the first 48 hours postoperatively. The percentage of patients with no postoperative complications (nausea, vomiting, and headache) was higher in the MNB group (76.7 %) compared with the control group (40 %). Patient satisfaction was statistically significantly higher in the MNB group (P < 0.001).

    Conclusions

     Bilateral ultrasound-guided suprazygomatic MNB appeared to be safe and advantageous, as its use was associated with a decrease in total analgesic consumption, a reduction in postoperative morbidities such as pain, nausea, and vomiting, and greater patient satisfaction.

    Keywords: Functional Endoscopic Sinus Surgery, Maxillary Nerve Block, Ultrasound Guidance, Perioperative Analgesia
  • Seyed Ali Golrokh Moghadam, Amin Tajerian, Behnam Mahmoudieh, Mohsen Parsi Khamene, Alireza Kamali * Page 4
    Background

     Total knee arthroplasty (TKA) is a standard surgical procedure for individuals with debilitating knee arthritis. Effective postoperative pain management is essential for successful recovery, although traditional opioid-based methods have limitations.

    Objectives

     This study aimed to compare the efficacy of Apotel and Remifentanil patient-controlled analgesia in managing postoperative pain after TKA.

    Methods

     This double-blind, randomized, controlled clinical trial took place at Amir-al-Momenin and Qods Hospitals in Arak, Iran, spanning from June 2022 to September 2023. Sixty-two eligible patients scheduled for knee joint replacement were randomly assigned to receive either Apotel (Group A) or Remifentanil (Group R) as part of multimodal analgesia administered via a pain pump for postoperative pain relief in TKA. The study assessed hemodynamic parameters, pain levels (measured using the Visual Analog Scale), analgesic duration, and narcotic consumption. Statistical analyses were performed using SPSS v.27 and Plotly.

    Results

     Subjects exhibited no statistically significant differences in age, gender distribution, duration of surgery, or anesthesia. The hemodynamic status assessment in the recovery room showed no significant differences in SPO2, PR, or MAP between the groups. However, Remifentanil demonstrated superior effectiveness in reducing pain over 24 hours post TKA surgery compared to Apotel, as evidenced by lower average Visual Analog Scale (VAS) scores (P < 0.001), longer duration without the need for narcotic painkillers (P < 0.001), and lower cumulative opioid analgesic consumption in Group R (P < 0.001).

    Conclusions

     Remifentanil demonstrates superior pain control in a multimodal pain management approach compared to Apotel, providing sustained pain reduction over 24 hours post-surgery. Moreover, Remifentanil offers longer-lasting pain relief and results in lower cumulative narcotic painkiller consumption compared to Apotel.

    Keywords: Knee, Arthroplasty, Pain Management, Remifentanil, Opioid Tolerance, Infusion Pumps
  • Aliakbar Nasiri *, Farzad Farajzadeh Vajari, Shahryar Sane, Roghaiyeh Afsargharehbagh Page 5
    Background

     The ganglion impar block is a minimally invasive technique used for alleviating pain associated with coccydynia.

    Objectives

     This research evaluates the effectiveness of the ganglion impar block in treating patients with coccydynia who have not benefited from conservative treatments.

    Methods

     This cross-sectional analysis reviewed the clinical records of coccydynia patients who received ganglion impar block injections at Urmia Imam Khomeini Hospital, Urmia, Iran, between 2020 and 2022. Data regarding age, gender, body mass index (BMI), onset of pain, and levels of patient satisfaction post-treatment were gathered from the medical records.

    Results

     The study comprised 26 patients, with 4 (15.4%) being male and 22 (84.6%) female. The average age and BMI were 39.15 ± 14.24 years and 28.91 ± 2.14 kg/m2, respectively, which did not show significant variation (P = 0.19). The average Visual Analogue Scale (VAS) score before the ganglion impar block was 6.23 ± 2.35, which reduced to 4.47 ± 2.41 immediately after the procedure. At the 1-month follow-up, the average VAS score had further decreased to 3.47 ± 0.79. The decrease in VAS scores, both immediately after the procedure and at the 1-month follow-up, was statistically significant. The success rate of the block (defined as a reduction in pain of at least 20% from the baseline) was significantly high immediately and one-month post-procedure (P < 0.001). Out of the 26 patients treated with the impar block, satisfaction rates were 42.3% excellent, 27% good, 19.2% fair, and 11.5% poor.

    Conclusions

     The study endorses the trans-sacro-coccygeal “needle inside needle” method for providing relief to patients suffering from coccydynia. The findings revealed significant patient satisfaction, with the majority describing their experience as excellent.

    Keywords: Coccydynia, Pain Management, Ganglion Impar Block, Treatment
  • Karim Hemati, Parniyan Hematy, Saeid Rahimi Ghasabeh, Ali Shokooh * Page 6

    Spinal decompression is a common procedure in spinal, neurosurgery, and orthopedic surgery. While there are a number of known complications associated with it, pneumocephalus (air in the brain) is generally not a recognized complication postoperatively. However, in rare cases, it can occur as a result of spinal decompression surgery. We describe a case of a 54-year-old female patient who developed pneumocephalus following percutaneous lumbar disc decompression surgery of the lumbar spine. The patient presented to the emergency department 3 hours after discharge with severe restlessness, cognitive impairment, nausea, vomiting, and lack of balance. During symptomatic treatment in the emergency department and 1 hour after taking oxygen, the patient’s vital signs improved. Before discharge, a computed tomography (CT) scan was taken again, which showed the disappearance of radiological symptoms. The patient was discharged 12 hours after hospitalization with suitable clinical conditions. Obtaining urgent imaging tests (magnetic resonance imaging [MRI] or CT) at the cranial and spinal levels, along with an electroencephalogram, allows us to diagnose the problem and determine the appropriate course of treatment, whether pharmacological or surgical.

    Keywords: Lumbar Decompression Surgery, Pneumocephalus
  • Olumuyiwa Akinwumi Bamgbade *, Monisola Temidayo Sonaike, Leili Adineh-Mehr, Daniel Olutosin Bamgbade, Zaina Samir Aloul, Cherith Boatametse Thanke Page 7
    Background

     Patients with chronic pain often experience psychological issues. They may also exhibit harassing behaviors toward healthcare staff. This complex sociomedical issue necessitates increased attention.

    Objectives

     This study analyzed incidents of staff harassment caused by chronic pain patients. It examined the characteristics of chronic pain patients who harassed clinic staff, as well as the causative or associated factors. The study also explored the management and outcomes of these harassment incidents.

    Methods

     This prospective observational study involved 1102 chronic pain patients who received treatment at a pain clinic. Data were prospectively collected on patients' gender, age, ethnicity, occupation, injury insurance claims, and incidents of staff harassment caused by patients.

    Results

     Pain clinic staff were harassed by 121 patients (11 %). Among the harassers, females constituted 70.2 % and males 29.8 %. Additionally, 50.4 % of the harassers were unemployed, with unemployed patients causing more staff harassments (P = 0.001). A significant portion, 86 %, of the harassers had injury insurance claims and were associated with a higher incidence of staff harassments (P = 0.002). Patients making disability insurance claims also caused more staff harassments (P = 0.001). Among the harassers, 50.4 % demanded higher drug doses, and 50 % did not have regular primary healthcare providers. The types of harassment included insults (34.7 %), threats (19.8 %), retaliations (3.3 %), and sexual harassment (42.2 %). All cases of sexual harassment were addressed; the patients involved were counseled. Most harassment incidents were resolved through tactful communication. Of the harassers, 9.9 % were discharged from the clinic.

    Conclusions

     Harassment of pain clinic staff by chronic pain patients is significant. This sociomedical issue may be worsening due to factors such as opioid misuse, racism, the pandemic, and socioeconomic challenges. While most chronic pain patients are reasonable, some can be challenging. This study confirmed that the majority of patients who harassed staff were female, unemployed, had made injury insurance claims, and demanded higher drug doses. Abusive patients should receive anxiolytic therapy, behavioral boundaries, counseling, distraction therapy, and empathy. Pain clinics should implement staff training and support programs to protect staff from harassment. Additionally, pain clinicians should establish peer support networks to mitigate the psychological impacts of patient aggression and maintain professional well-being.

    Keywords: Chronic Pain, Medical Sociology, Workplace Harassment, Protection of Healthcare Workers, Healthcare Racism, Sexual Harassment, Retaliation Harassment, Opioid Dependency, Sedative Dependency
  • Payman Dadkhah, Masoud Hashemi, Mehrdad Taheri, Ali Alizadeh Ojoor, Milad Jaffari, Alireza Jaffari * Page 8
    Background

     Chronic low back pain (CLBP) is a common issue among older adults. Radicular pain syndromes are often managed with caudal epidural injections. Our study aimed to compare the effects of triamcinolone and magnesium sulfate, used as adjuvants to local anesthetics in caudal blocks, on pain levels and quality of life in patients with LBP.

    Methods

     A total of 40 patients undergoing caudal block were randomized to two groups,received 10 mL caudal epidural injection of either injection 9 mL of ropivacaine 0.1% and 1 mL of triamcinolone; 40 mg (Group T, n = 20) or magnesium sulfate; 200 mg (group M, n = 20). Improvements in the pain score measured with the Visual Analog Scale (VAS) and functional ability measured with the Oswestry Disability Index (ODI) were the primary and secondary outcome measures, respectively. Before, one month and three months after the caudl block, the VAS and ODI scores were evaluated.

    Results

     The VAS and ODI scores did not exhibit a significant difference between the 2 groups at all post-injection time points, except for the VAS score at 3 months, which showed a statistically lower value in group M compared to group T (P = 0.046). However, when comparing within the same group, both groups showed significantly improved VAS and ODI scores at all post-injection time points compared to the pre-injection scores (P < 0.0001).

    Conclusions

     The addition of magnesium or triamcinolone to a local anesthetic in caudal epidural injections does not result in any discernible difference. However, this combination may lead to improvements in pain levels and quality of life, and these improvements can be sustained for up to 3 months.

    Keywords: Caudal Block, Low Back Pain, Magnesium Sulfate, Triamcinolone
  • Diya Sarah Jacob, Sonal Bhat *, Sunil Vasudev Rao Page 9
    Background

     Airway management of patients with long-standing diabetes poses a major challenge for anaesthesiologists due to stiff joint syndrome affecting the atlanto-occipital joint. In certain cases requiring immobilization, the Mallampati test must often be performed in the supine position for obvious reasons.

    Objectives

     Hence, we determined the diagnostic precision (sensitivity and specificity) of the modified Mallampati test in sitting and supine positions among the diabetic population in predicting difficult tracheal intubation.

    Methods

     A single-center prospective observational study on adult diabetic patients undergoing general anesthesia and orotracheal intubation was carried out. An observer recorded the modified Mallampati in the sitting posture during the pre-anesthetic examination. The Mallampati in the supine position was determined while in the operating room, and the difficulty of intubation was noted, and diagnostic precision was calculated. The main objective was to predict a difficult airway by calculating the sensitivity, specificity, positive predictive value, and negative predictive value.

    Results

     Out of the 150 participants, Mallampati grading in a sitting position was correctly able to identify 42.5% of difficult intubation cases, whereas it was 97.5% with Mallampati in the supine position. Mallampati grading in the sitting position was able to correctly identify 89.1% of easy intubation cases, which was 63.6% with Mallampati in the supine position. The correlation of Mallampati in the supine position with CL grading was statistically significant (P < 0.001).

    Conclusions

     Among diabetic patients, the modified Mallampati test in the supine position can be considered a more accurate and sensitive predictor of difficult intubation than the sitting posture.

    Keywords: Mallampati, Supine, Sitting, Diabetic, Difficult Intubation
  • Reyhaneh Faghihian, Aryana Golabbakhsh *, Elahe Asnaashari Page 10
    Background

     The application of local anesthesia in dental surgeries conducted under general anesthesia poses a challenge in pediatric dentistry. There is a lack of consensus regarding the benefits and drawbacks of using general anesthesia in this field.

    Objectives

     The purpose of this study was to assess the attitudes and practices of pediatric dentists regarding the use of local anesthesia for dental treatments in children under general anesthesia in Iran.

    Methods

     This cross-sectional study involved 110 pediatric dentists from across Iran. The dentists' professional attitudes and practices were assessed using a specially designed questionnaire for this study. The questionnaire was distributed through the Line press system, and the data were analyzed following collection.

    Results

     Regarding professional practices, 34.5% of specialists refrained from using local anesthesia. The most frequent application of local anesthesia was observed in tooth extractions. The preferred local anesthetic agent was 2% lidocaine with 1:100 000 epinephrine. A lower dose than that used in outpatient settings was administered, and most specialists allowed sufficient time for the anesthesia to take effect.

    Conclusions

     This study revealed that opinions and attitudes towards the use of local anesthesia in the dental treatment of children under general anesthesia vary across different specialties and are significantly influenced by the patient's condition, type of treatment, and practice techniques.

    Keywords: Attitude, General Anesthesia, Local Anesthesia, Pediatric Dentistry, Professional Practice
  • Ahmed El-Tawansy *, Ahmed MohamedSalama Elnajar, Hossam Abdel Baky Mahmoud, MohamedIbrahim Amin, Ahmed Abd Elmohsen Bedewy Page 11
    Background

     Ultrasound (US) of the upper airway has the potential to be a valuable addition to traditional clinical evaluation methods.

    Objectives

     This work aimed to assess the validity of US in correlation with Cormack-Lehane grading (CLG) in obese patients.

    Methods

     This cross-sectional work was performed on 78 patients ranging in age between 21 and 60 years, both genders with the American Society of Anesthesiologists (ASA) II-III individuals and body mass index (BMI) 30 kg/m² or more, under general anesthesia with endotracheal tube placement. Each separate finding by the US and conventional clinical airway assessment methods before anesthesia induction correlated to the CLG of the same patient after the induction of anesthesia. Grades III and IV are categorized as difficult laryngoscopy.

    Results

     A significant positive association existed among CLG and duration of US measures, pre-epiglottis spaces (Pre-E) ratios, to the distance between a point mid away vocal cords and epiglottis, Pre-E, ratio of hyomental distance extension/hyomental distance neutral and Mallampati; however, there was a significant negative correlation with skin to anterior commissure, hyomental distance extension, hyomental distance neutral, sternomental distance, and thyromental distance (P < 0.05). The ratio between Pre-E over the distance between the epiglottis and a point midway through the vocal cords at cut-off > 2.23 can discriminate difficult laryngoscopy with sensitivity 100% and specificity 100% and area under the curve of 1.

    Conclusions

     The sonographic assessment of the upper airway aids in predicting individuals who might have challenges with airway management. A reliable indicator of a challenging laryngoscopy was the sonographic parameter ratio of Pre-E to the distance between the vocal cords' midway point and the epiglottis.

    Keywords: Ultrasound, Laryngoscopy, Obesity
  • Shahrokh Ebnerasooli, Arash Barghi *, Karim Nasseri, Nasrin Moghimi Page 12
    Background

     Osteoarthritis (OA) is a chronic health condition that affects millions of people worldwide. It not only causes pain and physical limitations but also impacts mental health, sleep, work participation, and even mortality. Peri-articular dextrose prolotherapy has been shown to reduce knee osteoarthritis pain; however, the effect of injection sites on its effectiveness is not clear.

    Objectives

     This study aimed to investigate the effect of injection points on pain intensity, joint stiffness, and physical activity in patients with knee osteoarthritis who underwent peri-articular dextrose prolotherapy.

    Methods

     This double-blind clinical trial involved 26 patients with grade 2 and 3 bilateral knee osteoarthritis. Three times every one week, dextrose and lidocaine were injected as interventions. Injection sites were positioned within acupuncture points on one knee, but were relocated by 1.5 centimeters to the medial side of the same acupuncture points on the other knee. Pain intensity, joint stiffness, and physical activity were evaluated using the Visual Analog Pain Scale (VAS) and the Persian version of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before the intervention and at each follow-up visit at 1 and 2 months post-injection.

    Results

     Pain intensity score, joint stiffness, physical performance, and WOMAC were significantly decreased one and two months after the intervention in both groups (P = 0.0001). The improvement in the patients of both groups was similar, and the two study groups did not have a statistically significant difference in terms of study outcomes (P = 0.37).

    Conclusions

     Prolotherapy with dextrose is an effective treatment for knee osteoarthritis.

    Keywords: Dextrose Prolotherapy, Knee Osteoarthritis, Pain, Peri-articular, WOMAC
  • Ahmed Abd Elmohsen Bedewy, Maged Salah Mohamed, Hesham Mohamed Sultan *, Moataz Salah Khalil Page 13
    Background

     Modified radical mastectomy (MRM) is the primary surgical treatment for breast cancer, yet it leads to significant postoperative pain.

    Objectives

     This randomized controlled trial evaluates the effects of an erector spinae plane block (ESPB) versus a serratus anterior plane block (SAPB) on post-MRM pain management and stress response reduction.

    Methods

     Sixty individuals scheduled for unilateral MRM under general anesthesia from October 2021 to October 2022 were divided into three groups. Group A comprised 20 patients who received ultrasound-guided ESPB (20 mL of 0.25% bupivacaine). Group B included 20 patients who received ultrasound-guided SAPB (20 mL of 0.25% bupivacaine). Group C was treated with intravenous morphine based on pain scores. Anesthesia was induced using 2 μg/kg of fentanyl and 2 - 3 mg/kg of propofol. The study compared the three groups regarding pain scores using a numerical rating scale, serum cortisol levels, total fentanyl, and morphine consumption, changes in mean arterial blood pressure (MAP) and heart rate (HR) during surgery, and the occurrence of postoperative complications.

    Results

     Statistically significant reductions in pain scores were observed in group A compared to groups B and C. Moreover, group A exhibited a significant decrease in postoperative morphine consumption, serum cortisol levels 1 hour post-surgery (P = 0.021), MAP, and postoperative vomiting and nausea compared to group B. Furthermore, groups A and B showed statistically significant improvements in all parameters compared to group C.

    Conclusions

     The study demonstrates that ESPB provides superior analgesic effects compared to SAPB in patients undergoing MRM, with reduced morphine use and lower postoperative cortisol levels. Both blocks offer more effective pain control than intravenous morphine alone.

    Keywords: Erector Spinae Plane Block, Serratus Anterior Plane Block, Modified Radical Mastectomy, Stress Response, Analgesia