Anesthesiology and Pain Medicine
Volume:4 Issue: 3, Aug 2014

Cardiovascular problems are among the most common health issues. A considerable number of cardiac patients undergo cardiac surgery, and coronary artery disease patients constitute about two-thirds of all these surgeries. The application of cardiopulmonary bypass (CBP) usually results in some untoward effects.. Studies have suggested magnesium sulfate (MgSO4) as an anti-inflammatory agent in a coronary artery bypass graft (CABG). This study aimed to assess the effect of an IV MgSO4 infusion during elective CABG (with CBP) on the blood levels of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α).. During a 12 month period, after review board approval and based on inclusion and exclusion criteria, 90 patients were selected and entered randomly into one of the two study groups (MgSO4 or placebo). Anesthesia, surgery and CBP were performed in exactly the same way, except for the use of MgSO4 or a placebo. Both preoperative and postoperative plasma levels of IL-6 and TNF-α were checked and compared between the two groups using an ELISA.. There was no difference found between the two groups with regard to; gender, basic variables, Ejection Fraction (EF), CBP time and aortic cross-clamp time. The preoperative levels of IL-6 and TNF-α were not different; however, their postoperative levels were significantly higher in the placebo group (P value = 0.01 for IL-6 and 0.005 for TNF-α).. This study showed that MgSO4 infusion could suppress part of the inflammatory response after CABG with CBP. This was demonstrated by decreased levels of interleukin-6 and TNF-α in postoperative serum levels in elective CABG with CBP..

Xeroderma Pigmentosum (XP) is a rare autosomal recessive disease, which is defined by extreme sensitivity to sunlight and UV radiation and characterized by skin lesions and neuromuscular abnormalities. It is caused by a molecular defect in nucleotide excision repair genes. It has been reported that volatile anesthetics may cause genotoxic side effects or aggravation of the neurological signs. We report an XP patient with difficult intubation whose airway was controlled with Laryngeal Mask Airway (LMA) and was anesthetized with sevoflurane. A 23-year-old woman, who had been a known case of XP since her childhood, was admitted to our hospital for excision of face mass (SCC) and skin graft surgery. Her airway examination revealed some anatomical and pathological abnormalities, including limitation of mouth opening, jaw protrusion, head extension, and class 4 of mallampati, all predicting difficult intubation. We chose general anesthesia with inhalation induction, LMA insertion and maintenance with sevoflurane without muscle relaxant. The surgery was completed uneventfully and the patient left the hospital the day after the surgery without any new complaint. We suggest that for XP patients with compromised air-way, sevoflurane (not all volatiles) may be preferred.

This randomized, clinical trial evaluates the analgesic and safety of paracetamol and Morphine in management of headache. This study aimed to evaluate the analgesic and safety effects of intravenous single dose of paracetamol, versus morphine in post trauma headache in emergency departments.Patients and This study was a single-center, prospective, randomized, double-blind clinical trial conducted on two groups treated with intravenous paracetamol and intravenous morphine. Thirty patients were enrolled in each group. Patients (18-55 years-old adults) complaining from headaches due to pure trauma were included in the study. The inclusion criteria required patients to have headachesof more than 40 mm on a 100 mm visual analogue scale without any pathological findings in their clinical examinations and imaging studies. Mean duration required to treat the headache was 37.43 and 71.93 minutes in the groups administered paracetamol (group A) and morphine (group B), respectively. After 15 minutes of treatment, this changed to 31.7 ± 18.0 mm (95% CI 8.2 to 25.2) and 48.3 ± 14.1 mm (95% CI 8.2 to 25.2) in groups A and B, respectively. Headache of the patients of group A significantly mitigated in comparison with group B (P < 0.005). Headache of group Apatients was significantly mitigated 30 minutes after treatment (P < 0.005). Intravenous paracetamol is an effective and safe treatment for patients admitted to the emergency department with headaches caused by head trauma.

The prevalence of chronic postoperative pain after cardiac surgery has been reported from 17% to 56%. We aimed to compare the prevalence of postoperative pain between patients who had undergone CABG using the internal mammary artery (IMA) and those who had undergone other cardiac surgeries including CABG using the saphenous vein or cardiac valvular surgeries.Patients and In this cohort study, medical records of 188 patients were evaluated and divided into two equal groups (94 in each group); patients who had undergone CABG using the IMA (IMA group) and those who had undergone other cardiac surgeries using the saphenous vein or other cardiac valvular surgeries (non-IMA group). The patient's data were recorded in a self-structured questionnaire and then phone interviews were performed 3 months after the operations regarding the rate of postoperative pain. The severity of chronic pain was rated based on the numerical rating pain scale. The two groups differed significantly regarding the prevalence of pain (P = 0.023). In the IMA group, 83 (88.3%) patients experienced pain lasting for more than three months compared to 71 (75.5%) patients in non-IMA group. The two groups differed significantly with respect to the severity of chronic pain after cardiac surgery via sternotomy (P = 0.001). The groups did not differ significantly regarding the effects of chronic pain on their sleep, referral to a physician, and drug consumption to alleviate their pain. The IMA group experienced more complications at work and during their occupational activity. The rate and severity of chronic pain after cardiac surgery via sternotomy was higher in patients undergoing CABG with separation of IMA for revascularization.

There have been many concerns about alteration in hemodynamic parameters within and shortly after endotracheal intubation (ETI) in patients scheduled for elective coronary artery bypass grafting (CABG). We compared the attenuation effect of magnesium sulfate and lidocaine on hemodynamic responses after ETI, in patients undergoing CABG.Patients and In this randomized controlled trial 150 patients undergoing elective CABG were enrolled. Included patients were randomly allocated to three groups and received lidocaine (1.5 mg/kg), magnesium sulfate (50 mg/kg within five minute), or normal saline, 90 seconds before ETI. Baseline hemodynamic parameters including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded immediately before anesthesia induction, before intubation, immediately after intubation, and at second and fifth minutes after intubation. The baseline hemodynamic variables had no deference among the three groups. HR between intubation and five minute after intubation was significantly lower in two groups received lidocaine or magnesium sulfate in comparison with placebo group. Lidocaine induced more than 20% decrease in HR and MAP immediately after intubation; hence, lidocaine group showed significant MAP reduction in comparison with the two other groups. Lidocaine induced hemodynamic instability but premedication of magnesium sulfate maintained hemodynamic stability after intubation. Therefore, in patients undergoing CABG who received high-dose intravenous analgesic for general anesthesia, the administration of magnesium sulfate might result in maintaining hemodynamic stability after ETI in comparison with lidocaine.

Postoperative pain is a common complication that can lead to serious morbidities and delayed recovery. The aim of this study was to investigate the effect of low-level laser therapy on acute pain after tibial fracture surgery.Patients and In this randomized clinical trial, 54 patients who were candidate for tibial fracture surgery were allocated randomly to two groups, namely, control and laser therapy. Both groups had the same type of surgery and technique of spinal anesthesia. Patients in laser group were treated with the combination of two lasers (GaALAs, 808 nm; and GaALInP, 650 nm) at the end of the surgery while control group received laser in turn-off mode with the same duration as laser group. Patients were evaluated for pain intensity according to the visual analogue scale (VAS) and the amount of analgesic use during 24 hours after surgery. Laser group experienced less pain intensity in comparison with control group at second, fourth, eighth, 12th, and 24th hours after surgery (P Value < 0.05). In addition, the amount of consumed opioid in laser group was significantly less than the control group (51.62 ± 29.52 and 89.28 ± 35.54 mg, respectively; P Value, 0.008). Low Level Laser Therapy is a proper method to reduce postoperative pain because it is painless, safe, and noninvasive and is easily accepted by patients.

Combining different analgesic drugs for improvement of drug efficacy is a recommended strategy intended to achieve the optimal therapeutic effects. The purpose of the present study was to assess the nature of the interaction between ascorbic acid and two analgesic drugs, morphine and tramadol. The analgesic activity was assessed by the acetic acid writhing test in male Naval Medical Research Institute (NMRI) mice. The results were obtained using four to six animals in each group. All the drugs were injected intraperitoneally. The effective doses(ED) that produced 20%, 50%, and 65% antinociception (ED20, ED50 and ED65) were calculated from the dose-response curve of each drug alone as well as co-administration of ascorbic acid and tramadol or morphine. The interaction index was calculated as experimental ED/theoretical ED. For each drug combination, ED50, ED20, and ED65 were determined by linear regression analysis of the dose-response curve, and they were compared to theoretical ED50, ED20 and ED65 using t-test. The antinociceptive effects of all drugs were dose-dependent (ED50was 206.1 mg/kg for ascorbic acid, 8.33 mg/kg for tramadol, and 0.79 mg/kg for morphine).The interaction index demonstrated additive effects at ED50 and ED65 for co-administration of ascorbic acid and tramadol or morphine. However, at ED20, combination of ascorbic acid and tramadol or morphine showed synergic effects. The interaction index values of the combinations demonstrated the potency ratio of ascorbic acid/morphine to be lower than ascorbic acid/tramadol. This study demonstrated the results of interactions between ascorbic acid and tramadol or morphine. The results showed that the interaction effects on antinociception may be synergistic or additive, depending on the level of effect.

There are many references in ancient Iranian literature on anesthesia, analgesia and pain. Various cultural changes have occurred due to political, cultural and civil factors, one key example being the bilateral interactions between Iranian culture and other cultures with regards to many issues, involving medicine and medical sciences, a process that has been part of the dialogue between civilizations. Some aspects of ancient Iranian culture have been cited in Iranian literature, often involving Iranian physicians. Iranian scientists of earlier times possessed a great wealth of knowledge in the fields of medicine, philosophy, literature, astrology, etc. and they recorded their experiences for posterity. Ancient Iranian culture cites the writings of many famous and great scientists and poets. Two main cultural eras are defined in Iranian culture: pre-Islamic and Islamic. In this manuscript, the recorded histories of anesthesia, analgesia and pain are followed according to this historical classification. Throughout the manuscript pain is frequently mentioned, because pain is one of the key issues often mentioned in Iranian literature, especially by the romantic poets, mainly as a sign of ‘love’ from the ‘lover’ expressed towards the ‘beloved one’. Lover in Farsi is Aashegh and the beloved one is Mashough; two terms that will be mentioned throughout this manuscript.

Evaluation of operational risk is a consequential goal in perioperative management of patients in cardiac surgery. Preoperative total lymphocyte count (PTLC) is a prognostic criterion of adverse major cardiovascular outcomes. The purpose of this study was to investigate the prognostic value of PTLC as an independent predictor of postoperative morbidity and mortality in cardiac surgery.Patients and Of 1604 patients scheduled for cardiac surgery between September, 2012 and March, 2013, a total of 1171 consecutive patients underwent elective primary valvular heart surgery and coronary artery bypass grafting. The patients were divided to three groups according to their PTLCs. The baseline characteristics and postoperative mortality and morbidity of the patients as well as the intensive care unit (ICU) stay according to the PTLCs were recorded and analyzed. The only inclusion criterion was a preoperative complete blood count. Exclusion criteria included: ages under 18 or over 80 years old, emergency surgery, adult patients with congenital heart disease and previous open heart surgery, and patients with any bacterial or viral infection during two weeks before the surgery. Protocol of anesthetic medications was used in all the patients similarly and according to standard. All the patients were admitted to the ICU after the surgery. A PTLC < 1500 cells/µL was associated with significantly high mortality and morbidity (P = 0.0001). In-hospital mortality and major composite morbidity were 9.65% and 28.4%, respectively. Low PTLC was associated with more frequent need for inotropic and intra-aortic balloon pump (IABP) support (P < 0.001), dialysis-dependent acute renal failure (P = 0.0001), postoperative superficial wound infections (P = 0.0001), and prolong ICU stay (P = 0.0001). Our study results showed that low PTLC was an independent, valuable prognostic criterion, with high sensitivity and specificity for evaluation of postoperative morbidity and mortality in cardiac surgery.

Hydatid cyst is a parasitic disease caused by a tapeworm Echinococcusgranulosus. Humans are accidental hosts and infected after digestion of foods contaminated to fecal matter of definite hosts. The most affected organs are liver and lungs. Rupture of cyst (spontaneous rupture or rupture due to trauma or surgery) can cause anaphylactic reactions. Even considered as a rare event during anesthesia, it can be life threatening with the manifestations of severe hypotension and circulatory shock. Thus, immediate and proper treatment is necessary. We report a case of anaphylactic shock during surgery of pulmonary Hydatid cyst in a 42 year old woman and its management. During the surgery of hydatid cyst, any hemodynamic instability should raise the suspension of anaphylaxis and early resuscitation should be instituted.

Postherpetic neuralgia (PHN) is a frequently occurring neuropathic pain, its pathophysiology is not fully understood. There are only few evidence based therapeutic options; sympathetic nerve block can be considered for patients with PHN refractory to conservative treatment, but long-term effects are poor. Application of pulsed radiofrequency was effective to treat a variety of pain syndromes without neurological complications or other sequelae. We observed a remarkable long-lasting pain relief in patients with post herpetic neuralgia (PHN) treated with caudal epidural PRF. We described the technique of caudal epidural PRF and three case reports. The mode of action of PRF is far from being completely elucidated. The high frequency current induces an electric field that in turn seems to influence the immunity, the inflammation and other pain conducting mechanisms. Our findings suggest an effect distal from the application of the current. It reaches targets that are difficultly attainable by any other means of current application. The observations of pain relief in the difficult to treat patients with PHN justifies further investigation.

According to the previous studies, antihypertensive drugs should be withdrawn before surgery. Nowadays it is accepted that some drugs effectively control systemic blood pressure (BP) to assure its desirable therapeutic control. In this study, the effects of captopril, an angiotensin converting enzyme inhibitor (ACEI), on hemodynamic changes before, during, and after the coronary artery bypass graft (CABG) surgery was studied.Patients and In this study, 54 patients were randomly selected in the cardiac surgery ward of Ahvaz Golestan Hospital. Amongst them, 27 patients (control group) did not consume any ACEI for controlling BP but the remained 27 patients (experimental group) used the drugs. In these groups, the effects of captopril on hemodynamic changes before, during, and after surgery were studies. Two groups did not have any significant differences in oxygen saturation (P value: before, 0.15; during, 0.08; and after CABG, 0.53) and pulse rate (P value: before, 0.09; during, 0.25; and after CABG, 0.15). Nevertheless, they had significant differences in changes in systolic and diastolic BP in different time points (P Value of systolic BP: before, 0.001; during, < 0.001; and after CABG, 0.007; and P Value of diastolic BP: before, < 0.001; during, 0.001; and after CABG, 0.009). Using ACEI can effectively reduce the systolic and diastolic BP before, during, and after CABG surgery without any effects on oxygen saturation and pulse rate..

Postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy (LC) has multifactorial etiology. Pain and use of opioids are among the important factors. The present study aimed to evaluate the efficacy of intrapritoneal (IP) injection of bupivacaine on PONV.Patients and This was a double-blind randomized clinical trial, conducted on 66 patients aged 20-60, ASA I or II, candidates for LC. Patients were randomly assigned to two groups. Bupivacaine group received 20 mL bupivacaine 0.25% in the gallbladder bed, before and after cholecystectomy and the control group did not. The incidence of nausea and postoperative pain intensity was measured with Visual analogue scale (VAS) at 1, 2, 3 and 4 hours after operation, at rest and when coughing and changing positions. Nausea and vomiting occurrence were assessed at the same times. There were no demographic data differences between groups. No differences were found between the two groups, in terms of incidence of nausea and vomiting. Furthermore, both groups were similar with respect to opioid consumption, during four hours post-operation. Intraperitoneal bupivacaine administration at the beginning and end of laparoscopic cholecystectomy reduced only visceral and shoulder pains at the 4th postoperative hour, but had no effect on reducing neither PONV, nor opioid demand, during the first four postoperative hours.

Lumbar plexus block (LPB) is one of the anesthetic options in the elderly patients undergoing hip surgeries. LPB could be safe because it targets somatic nerve in psoas region. Effectiveness of LPB is attributed to the sufficient analgesia provided intraoperatively as well as postoperatively. Adequate muscle relaxation and immobility during surgery refers to its acceptability. In this study, LPB was used as the anesthetic method to manage the elderly patients subjected to hip surgery.Patients and A total of 50 patients aged 51 to 100 years were enrolled in this study. LPB was accomplished after a mild sedation and with a modified method using patient's fingertip width (FTW) as the distance unit to determine needle entry point under electrical nerve stimulation assistance. After targeted injection, procedure time, establishment time, block duration, surgery time, hemodynamic variables, and surgeon satisfaction score were documented and analyzed. Propofol in trivial doses was infused intraoperatively to provide clinical sedation. Mean patient's age was 73 ± 12 years with ASA II/III. Procedure time was 5.65 ± 1.24 minutes, establishment time was 130 ± 36 seconds, block duration was 13.1 ± 8 hours, surgery time was 149.7 ± 32.2 minutes, and surgeon satisfaction score was 9.8 ± 0.1. There was no complication and no failure. Hemodynamic stability was pleasantly achieved. By preserving hemodynamic stability, LPB in conjunction with a light sedation could be considered as a reliable prudent satisfying anesthetic option in management of hip fractures in the elderly patients with three beneficial characteristics of safety, effectiveness, and acceptability.