Anesthesiology and Pain Medicine
Volume:4 Issue: 2, May 2014

Side effects of spinal anesthesia are hypotension, bradycardia and shivering. Five-hydroxytriptamine (5-HT), a serotonergic receptor, may be an important factor associated with inducing the Bezold Jarish reflex (BJR) that may lead to the bradycardia and hypotension in the setting of decreased blood volume.. This study aimed to investigate the effect of intravenous administration of ondansetron, a 5-HT3 receptor antagonist, which could attenuate spinal-induced hypotension, bradycardia and shivering..Patients and Two hundred and ten patients aged 20-50 years old were scheduled for spinal anesthesia and were divided randomly into three equal groups. The control group received normal saline and intervention groups received 6 mg or 12 mg of intravenous ondansetron 5 minutes before spinal anesthesia. Mean arterial pressure (MAP), heart rate (HR), and shivering were recorded before and after spinal anesthesia every 5 minutes during first 20 minutes of surgery.. Demographic data were not statistically different among groups. HR was statistically different between the experimental groups and the control group. Ten patients (14%) in the control group had HR < 50 bpm, that required intravenous atropine compared to experimental groups (P =0.02). In the control group 12 (17%) patients had MAP < 80 mm Hg and required vasopressors compared to experimental groups (P = 0.04). There were no significant differences in MAP and HR between the experimental groups (P =0.06). Incidence of shivering in the control group was 45% (32.70) that was statistically more than experimental groups (P = 0.02).. Administration of two different doses of intravenous ondansetron, 6 mg and 12 mg, significantly attenuates spinal induced hypotension, bradycardia and shivering compared to the control saline group. However, the hemodynamic profiles and shivering in experimental groups were not statistically different..

One of the frequent applications of elastomeric infusion pumps is postoperative pain management. In daily practice, the disposable pumps get refilled with modified medication combinations in the successive days; although, the accuracy of infusion rates is unknown to clinicians.. Our aim was to evaluate the effect of repeated filling on the delivery rate accuracy of an elastomeric pump available in our market.. We examined 10 elastomeric infusion pumps (BOT-802, Nanchang Biotek Medical Device Company, China) with 100 mL capacity and nominal flow of 5 mL/h. Each pump was filled for three times, accounting for 30 series of experiments. A microset scaled in mL was used to measure the pump deliveries. Flow profile and reliability of infusion rate were analyzed after repeated use.. The mean flow rate in the three series of measurements showed a gradual increase; however, the difference was not statistically significant (5.01 ± 0.07 vs. 5.03 ± 0.06 vs. 5.06 ± 0.08 mL/h; P = 0.81). The percentage of the flow rate error (deviation from 5 mL/h ± 15%) was 100% in the first and second hours of infusion, 96% in the third hour, 60% in the 20th hour and zero percent in the rest of the infusion time.. This study indicated that the delivery rate accuracy of elastomeric infusion pumps is preserved after repeated usage. These laboratory findings suggested that elastomeric pumps could be safely refilled in the successive days to provide postoperative analgesia..

previous evidences suggested that traditional sitting position (flexion of knees approximately 90°, and adduction of hips while feet rest on a stool) and hamstring stretch position (sitting position with maximum extension of knees, adduction of hips, and forward bending) both reversed the lumbar lordosis and the number of spinal needle-bone contacts were identical when placing patients in these positions for neuraxial block.. In this study, we suggested that squatting position reverses the lumbar lordosis and reduces the number of spinal needle bone contacts better than a traditional sitting position..Patients and Two hundred and thirty six patients ASA (American Society of Anesthesiologist) class I or II aged 18 to 75 years scheduled for elective surgeries under elective spinal anesthesia were randomized into two groups. We compared the traditional sitting and squatting positions. Our primary endpoint was the number of spinal needle-bone contacts, and secondary endpoint was ease of needle insertion or space identification.. The total number of spinal needle bone contact was statistically lower in the squatting position compared to traditional sitting position group (222 versus 230 respectively, P = 0.01). Insertion of needle was easy in 97 (87%) and 94 (84%) of patients and difficult in 20 (18%) and 17 (15%) of patients in traditional sitting and squatting positions, respectively (P = 0.59 and P = 0.12). Needle insertion was not impossible in any patients.. In squatting position the number of spinal needle-bone contacts was lower compared to the traditional sitting position, nonetheless ease of needle insertion or space identification was the same in the both groups..

Postoperative visual loss (POVL) has become the focus of attention for anesthesiologists as a hallmark of perioperative management in spine surgery. A number of Intraoperative and postoperative factors has been documented but the exact etiology is still unclear. Nowadays, perioperative management and also complete curing of POLV is a big question of ophthalmologists and anesthesiologists. The purpose of this case report is to present a unique experience of complete curing the POLV.. Our patient was a 61-year-old man, with 75 kg weight and 180 cm height. The patient had no history of visual impairment except mild cataract in his right eye. The patient had a history of diffuse idiopathic skeletal hyperostosis (DISH). The patient had undergone lumbar surgery in prone position. The operation time was about 6 hours. About 30 minutes after transferring to postanesthesia care unit (PACU), patient was awake and complained of losing his eyesight. There was no vision and light perception in his right eye on primary examination. Urgent ophthalmologist consultation was requested. In ophthalmology examinations, the pupil reflex to light was absent in the right eye. After obtaining patients and his family informed consent, four hours after the operation, 40000 I.U. of recombinant human erythropoietin (rhEPO) was administered for patient in PACU (IV infusion, in 30 min). An ophthalmologist visited him every 6 hours after administration of rhEPO. The patient was transferred to intensive care unit (ICU) one hour later with total visual loss in the right eye. Ophthalmologic examination after the second dose of rhEPO, 30 hours after the operation, reported pupil reflex enhancement and light perception in his right eye. Finally the third dose of rhEPO (40000 I.U., IV infusion) was administered on the third day. Ophthalmologic examination after the third dose of rhEPO, 60 hours after the operation, reported normal pupillary light reflex of the right eye and visual acuity improvement to 20/20. The patient was discharged from hospital after six days, with normal visual acuity and without any new complications except surgical site pain.. Our case report showed the therapeutic effect of rhEPO in complete curing of POVL. Regarding the side effects of EPO such as thrombogenic effects or mild hemodynamic changes like transient sinus tachycardia during infusion, it seems that beneficial effects of EPO is more than its disadvantages and expenses, for patients with POVL..

Pheochromocytoma is a catecholamine-secreting tumor, which is seen rarely in children. These tumors predominantly secrete norepinephrine and epinephrine. They might be familial and associated with hereditary tumors such as Von Hippel-Lindau syndrome and multiple endocrine neoplasia type II.. The child might present with a spectrum of clinical manifestation including hypertension, headache, visual disturbances, and behavioral problems. A meticulous preoperative preparation is essential for a stable intraoperative and postoperative outcome. We described successful perioperative management of a child who underwent bilateral laparoscopic cortical sparing adrenalectomy and a repeated surgery for the residual tumor removal..

The addition of intrathecal opioids to local anesthetics seems to improve the quality of analgesia and prolong the duration of analgesia, when using a subarachnoid block in Iranian patients with their specific pain tolerance.. The aim of this study was to evaluate the effects of adding fentanyl or sufentanil, to intrathecal bupivacaine, in terms of the onset and duration of; sensory block, motor block, hemodynamic effects and postoperative pain relief..Patients and This randomized clinical trial included 90 patients who underwent orthopedic lower limb surgeries. Subjects were divided into experimental groups; intrathecal fentanyl 25 µg (F), and sufentanil 2.5 µg (S), along with a placebo 0.5 mL normal saline (C) group, which were added to bupivacaine 0.5%, 15 mg. Duration of complete and effective analgesia was recorded (by a visual analogue scale-VAS). The pain scores were assessed postoperatively. Intraoperative mean arterial pressure (MAP), heart rate and oxygen saturation (SPO2) were recorded. The incidence of side effects such as; nausea, vomiting, pruritus, shivering, bradycardia and hypotension were also recorded.. MAP and heart rate results showed no significant changes at the designated time points among the three groups (P > 0.05). However, SPO2 and VAS showed significant changes at the designated time points among the three groups (P < 0.05). The duration of complete and effective analgesia was also significantly longer in the sufentanil group (P < 0.05). Motor block did not exhibit any significant difference (P = 0.67). Only pruritus as a side effect was significantly higher in the sufentanil group (P < 0.05), while all other evaluated side effects were significantly lower in the sufentanil group (P < 0.05).. The addition of 2.5-3 mcg sufentanil to 15 mg 0.05% bupivacaine maintained the patient’s hemodynamic stability similar to fentanyl. Intrathecal sufentanil added to bupivacaine,when compared with fentanyl, may lead to prolonged duration of analgesia, facilitate the spread of the sensory block, increase mean SPO2 levels, and reduce overall side effects..

Opioids have been traditionally used for postoperative pain control, but they have some unpleasant side effects such as respiratory depression or nausea. Some other analgesic drugs like non-steroidal anti-inflammatory drugs (NSAIDs) are also being used for pain management due to their fewer side effects.. The aim of our study was to compare the analgesic effects of paracetamol, an intravenous non-opioid analgesic and morphine infusion after elective laparotomy surgeries..Patients and This randomized clinical study was performed on 157 ASA (American Society of Anesthesiology) I-II patients, who were scheduled for elective laparotomy. These patients were managed by general anesthesia with TIVA technique in both groups and 150 patients were analyzed. Paracetamol (4 g/24 hours) in group 1 and morphine (20 mg/24 hours) in group 2 were administered by infusion pump after surgery. Postoperative pain evaluation was performed by visual analog scale (VAS) during several hours postoperatively. Meperidine was administered for patients complaining of pain with VAS > 3 and repeated if essential. Total doses of infused analgesics, were recorded following the surgery and compared. Analysis was performed on the basis of VAS findings and meperidine consumption.. There were no differences in demographic data between two groups. Significant difference in pain score was found between the two groups, in the first eight hours following operation (P value = 0.00), but not after 12 hours (P = 0.14). The total dose of rescue drug (meperidine) and number of doses injected showed a meaningful difference between the two groups (P = 0.00). Also nausea, vomiting and itching showed a significant difference between the two groups and patients in morphine group, experienced higher levels of them.. Paracetamol is not enough for postoperative pain relief in the first eight hour postoperatively, but it can reduce postoperative opioid need and is efficient enough for pain management as morphine after the first eight hours following surgery..

Anesthesia in severe aortic stenosis, which describes a valve surface area less than 1 cm2, can result in rapid clinical deterioration and patient mortality. These patients may require treatment for aortic stenosis before any surgical intervention. In suitable patients percutaneous balloon aortic valvutomy appears to carry lower risk, but in emergency situations, it is important to determine which kind of anesthesia technique has the lowest risk for these patients, without any cardiac intervention.. In this case report, we present a patient who had tibia and fibula fractures and a symptomatic severe critical aortic stenosis which was diagnosed during a preoperative visit. The patient had exertional dyspnea, palpitations and fainting history, but he had not received any medical therapy before the present admission. During hospitalization and preoperative evaluation, a fat embolism occurred and the patient was admitted to the intensive care unit. Immediately after his recovery, we successfully managed the tibia and fibula fracture fixation without any cardiac intervention.. Our anesthesia method was sciatic and femoral nerve block under double ultrasonic and nerve stimulator guidance..

One of the unpleasant side effects of general anesthesia is shivering in the process of recovery. It is an involuntary oscillatory mechanical movement that can be classified as clonic movements. These movements can affect one or several groups of skeletal muscles beginning from 5 to 30 minutes after the discontinuation of anesthesia.. We aimed to study ketamine’s effect on shivering after operation compared to pethidine as a way for treatment of postoperative shivering..Patients and In this study, 60 patients who underwent ENT surgery with general anesthesia and had shivering during recovery were randomly divided into two groups of 30 patients each receiving ketamine (0.2 mg/kg IV) and pethidine (0.5 mg/kg).. There was no statistically significant difference between the shivering intensity in both groups. Only regarding the shivering in the first minute after entering the recovery room, there was an obvious difference between ketamine and pethidine groups which was again not statistically significant (P = 0.07).. The results of this study showed that ketamine and pethidine are both equally effective in the reduction of postoperative shivering..

Unilateral mydriasis is a seriously significant finding in neurologic examinations indicating life-threatening conditions such as cerebral vascular injuries.. A 24 year old woman with mandibular trauma was referred to our center after five days for a reduction of the right mandibular angle fracture. The patient had no history of any loss of consciousness after the accident. Her physical examination showed no abnormalities, except those related to her mandibular fracture. The laboratory results were normal as well. At 8:30 am a general anesthesia was induced. The patient’s eyes were kept shut throughout the surgical procedure. The operation included an intraoral open reduction and fixation using two miniplates without any complications. After the operation, it was noticed that the left eye was completely dilated with no reaction to light, while the right eye was normal. The management and outcomes in this patient were described in the present case report.. Evaluating the size of the patient’s pupils before, during and after the operation, careful history, consult, CT scan and MRI would help to diagnosis. Although no probable cause was found to explain the transient mydriasis in our patient..

Cluster headache is a severe hemifacial pain with concomitant symptoms such as lacrimation, conjunctival congestion, and nasal discharge. Peripheral (to be a spectrum of trigeminal autonomic cephalgia) and central (hypothalamus) disorders have been suggested to be involved. Several modalities have been recommended to prevent or alleviate this devastating headache.. In this case report, we presented a young man with an acute cluster headache who responded dramatically to the treatment with propofol and alfentanil.. Propofol and alfentanil combination can be considered as a treatment approach in the attack phase of cluster headache..

Recent years have witnessed the emergence of obesity as a major public health concern. The drastic rise in obesity and its concomitant co-morbidities is a reflection of the recent changes in dietary habits in Iran and many other developing countries. A recent large population study in Tehran reported that 58% and 75% of middle-aged Iranian men and women, respectively, were either overweight or obese.. Considering the impact of obesity on mortality and morbidity after coronary artery bypass graft surgery (CABG), we sought to investigate the association between central obesity and the body mass index (BMI) and the post-CABG mortality and morbidity in Iranian patients..Patients and This prospective study was on 235 adult patients scheduled for isolated CABG in a university hospital. The patients were divided in two groups according to BMI ≥ 30 (obese; n = 60) and BMI < 30 (non-obese; n = 175). In-hospital and late (after 3 months) morbidity and mortality rates were compared between obese and non-obese patients.. A total of 235 patients (135 women) with a mean age of 59 ± 9.2 years (range = 29 to 79 years), mean BMI of 27.3 ± 4.2 (range = 17 to 40), and mean waist circumference of 101.2 ± 14.7 cm (range = 55 to 145 cm) were included. By the third postoperative month, wound infection had significantly increased in patients with BMI ≥ 30 (P = 0.022). In-hospital and late morbidity and mortality rates were comparable between the two groups (P > 0.05).. In our patients obesity was a risk factor for wound infection but not atelectasis or the need for intra-aortic balloon pump or re-exploration. Obesity was not associated with increased in-hospital or 3 months mortality rates after CABG..

Spinal anesthesia is an important and commonly used method for surgical anesthetic in operating rooms. However, even with identical drug dosage and administration mode, the extent of drug distribution in vivo is highly variable and difficult to control. Preanesthetic administration of fluids immediately before spinal anesthesia (preload) is normal practice. The choice of fluid type may affect drug distribution as well as the duration and level of the block.. We examined whether preloads of normal saline, Ringer, or hydroxyethyl starch has different effects on the time it takes to reach maximum block, and the distribution and duration of spinal block level..Patients and This was a randomized trial and the 150 patients selected were evenly divided into three groups and given; normal saline, Ringer, or hydroxyethyl starch 130/0.4fluids. Preload was given at 10 mL/kg for the normal saline and Ringer groups, and 5 mL/kg for the hydroxyethyl starch group, 10 min before the spinal anesthesia. Sensory block levels were recorded every 5 min until 30 min after spinal anesthesia and then at 60 and 90min. Time taken to reach maximum and median sensory block, maximum and median level of block, duration of block, and hemodynamic status were recorded.. There were no statistically significant differences in the demographic characteristics between the three groups. Maximum block was higher in normal saline compared to Ringer (P = 0.029). Time taken to reach maximum block was greater in Ringer compared to both normal saline (P = 0.001) and hydroxyethyl starch (P = 0.003). Normal saline had a longer duration of sensory block T10 compared to Ringer and hydroxyethyl starch (P = 0.03).. Preload fluids have an impact on the level, distribution and duration of sensory block in spinal block. Of the three fluids, normal saline produced the greatest maximum and longest duration of block, whereas time taken to reach maximum block was longer in the Ringer group..

Anxiety is an unpleasant experience that may have adverse effects on the process of anesthesia, cesarean delivery, recovery period and postoperative pain. Anxiety can also affect maternal satisfaction of the medical cares that provided by the medical team.. To compare the effects of inhalational 50% nitrous oxide (N2O) with oxygen on reducing anxiety and pain in parturients who have undergone caesarean section under spinal anesthesia..Patients and In this double-blind clinical trial, 56 primigravid parturients were randomly assigned into two groups according to the operating list schedule. The experimental group received inhalational 50% N2O three minutes before spinal anesthesia to the end of delivery. The control group received only oxygen. Flow meters were covered by a dark shield and monitored by an experienced nurse anesthetist. Pain and anxiety of patients were measured using visual analogue scale (VAS) by another nurse who was neither involved in the anesthetic process nor aware of the participants'' allocation and inhalation agents. Data regarding sedation level, ephedrine use, nausea, vomiting, and neonate Apgar score were recorded as well.. Overall mean ± SD of anxiety VAS scores was 1.77 ± 1.5 in the experimental group and 3.12 ± 1.73 in the control groups (P = 0.003). The mean ± SD of pain VAS scores of the experimental and control groups were 0.82 ± 1.5 and 1.64 ± 1.45, respectively (P = 0.042). No significant differences were seen regarding blood oxygen saturation, neonate Apgar scores, total used ephedrine, operation time, delivery time, nausea, and vomiting between the two studied groups.. Inhalation of 50% N2O can significantly decrease anxiety (without clinically significant side effects) compared with O2 inhalation in parturients who have undergone caesarean section under spinal anesthesia..