Showing papers in "Anesthesiology and Pain Medicine in 2022"
TL;DR: The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings.
Abstract: One of the main objectives in neurosurgical procedures is the prevention of cerebral ischemia and hypoxia leading to secondary brain injury. Different methods for early detection of intraoperative cerebral ischemia and hypoxia have been used. Near-infrared spectroscopy (NIRS) is a simple, non-invasive method for monitoring cerebral oxygenation increasingly used today. The aim of this study was to systematically review the brain monitoring with NIRS in neurosurgery. The search process resulted in the detection of 324 articles using valid keywords on the electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, the full texts of 34 studies were reviewed, and finally 11 articles (seven prospective studies, three retrospective studies, and one randomized controlled trial) published from 2005 to 2020 were identified as eligible for systematic review. Meta-analysis was not possible due to high heterogeneity in neurological and neurosurgical conditions of patients, expression of different clinical outcomes, and different standard reference tests in the studies reviewed. The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings.
3 citations
TL;DR: Bilateral ultrasound-guided ESP blocks can be used to reduce perioperative opioid consumption in pediatric patients undergoing cardiac surgery through a sternotomy and it also can be use to decrease postoperative pain scores.
Abstract: Background Ineffective management of postoperative pain following pediatric cardiac surgeries adversely affects a patient’s postoperative course. The erector spinae plane (ESP) block has been described in the literature regarding perioperative pain management. We hypothesized that bilateral ESP blocks in pediatric patients would decrease intraoperative fentanyl consumption, reduce the need for postoperative morphine consumption, and improve pain scores. Objectives The aim of this double-blinded randomized controlled trial was to assess the efficacy and safety of bilateral ESP blocks in pediatric patients undergoing cardiac surgeries through a median sternotomy. Methods The study involved 98 children aged 6 months to 7 years who were American Society of Anesthesiologists (ASA) II and III and scheduled for cardiac surgery through a median sternotomy. Patients were divided randomly into 2 groups: the ES group (n = 50) who received bilateral ultrasound-guided ESP blocks, and the N group (n = 48) who received no block. The primary outcome was the total dose of administered fentanyl intraoperatively. Secondary outcomes included morphine consumption in the first 24 hours postoperatively; the length of time before the first need for postoperative analgesia; and FLACC (face, legs, activity, consolability, and cry) scores at the first and second hours postoperatively and every 4 hours, with readings taken for a period of 24 hours. Results There were statistically significantly higher levels of administered fentanyl intraoperatively (6.7 ± 3 vs 4.3 ± 1.9 µg.kg-1) and postoperative morphine consumption (0.5 ± 0.2 vs 0.4 ± 0.2 mg.kg-1) in the N group compared with the ES group (P < 0.001). Moreover, the timing of the first rescue analgesia was significantly delayed in the ES group compared with the N group (231.6 ± 104.5 vs 108.8 ± 47.8 minutes). Conclusions Bilateral ultrasound-guided ESP blocks can be used to reduce perioperative opioid consumption in pediatric patients undergoing cardiac surgery through a sternotomy. It also can be used to decrease postoperative pain scores.
3 citations
TL;DR: It is found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant, rendering the options of abandoning or continuing after duraluncture as reasonable methods.
Abstract: Background Spinal cord stimulation (SCS) is an important modality for intractable pain not amenable to less conservative measures. During percutaneous SCS lead insertion, a critical step is safe access to the epidural space, which can be complicated by a dural puncture. Objectives In this review, we present and analyze the practices patterns in the event of a dural puncture during a SCS trial or implantation. Methods We conducted a survey of the practice patterns regarding spinal cord stimulation therapy. The survey was administered to members of the Spine Intervention Society and American Society of Regional Anesthesia specifically inquiring decision making in case of inadvertent dural puncture during spinal cord stimulator lead insertion. Results A maximum of 193 responded to a question regarding dural punctures while performing a SCS trial and 180 responded to a question regarding dural punctures while performing a SCS implantation. If performing a SCS trial and a dural puncture occurs, a majority of physicians chose to continue the procedure at a different level (56.99%), followed by abandoning the procedure (27.98%), continuing at the same level (10.36%), or choosing another option (4.66%). Similarly, if performing a permanent implantation and a dural puncture occurs, most physicians chose to continue the procedure at a different level (61.67%), followed by abandoning the procedure (21.67%), continuing at the same level (10.56%), or choosing another option (6.11%). Conclusions Whereas the goals of the procedure would support abandoning the trial but continuing with the permanent in case of inadvertent dural puncture, we found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant. The majority chose to continue with the procedure at a different level while close to a quarter chose to abandon the procedure. This article sets a time stamp in practice patterns from March 20, 2020 to June 26, 2020. These results are based on contemporary SCS practices as demonstrated by this cohort, rendering the options of abandoning or continuing after dural puncture as reasonable methods. Though more data is needed to provide a consensus, providers can now see how others manage dural punctures during SCS procedures.
3 citations
TL;DR: In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.
Abstract: Background Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks. Objectives This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time. Methods In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI. Results The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.52 ± 1.83 vs 1.5 ± 2.84 (P = 0.03) on the first day, 0.70 ± 2.19 vs 1.58 ± 2.86 (P = 0.05) on the second day, and 0.82 ± 2.32 vs 1.18 ± 2.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups. Conclusions In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.
2 citations
TL;DR: In this article , a case series of four patients with confirmed SARS-CoV-2 infection undergoing acute or semi-urgent surgery was evaluated, and the authors concluded that elective surgery in asymptomatic SARS CoV-19 infected patients might elicit an exacerbated COVID-19 disease course.
Abstract: Introduction Current guidelines from the American Society of Anesthesiologists recommend postponing elective surgery on COVID-19-positive patients for a minimum of four to twelve weeks. However, literature focusing on the outcomes of COVID-19-positive patients undergoing surgery is scarce. In this case series, the outcome of asymptomatic COVID-19 patients undergoing acute or semi-urgent surgery was evaluated. Case Presentation A case series of four patients between 32 and 82 years old with a confirmed SARS-CoV-2 infection undergoing acute or semi-urgent surgery was presented here. All four patients were asymptomatic for COVID-19, developing severe respiratory failure following endo CABG, caesarian section, a thyroidectomy, or abdominal surgery. ICU admission, together with invasive ventilation, was necessary for all patients. Two patients required venovenous extracorporeal membrane oxygenation treatment. A mortality of 50% was observed. Conclusions In conclusion, the present case series suggests that elective surgery in asymptomatic SARS-CoV-2 infected patients might elicit an exacerbated COVID-19 disease course. This study endorses the current international guidelines recommending postponing elective surgery for SARS-CoV-2-positive patients for seven weeks, depending on the severity of the surgery and perioperative morbidities, to minimize postoperative mortality.
2 citations
TL;DR: The PECS-II block is more effective in postoperative pain control after breast cancer surgery than the ESP block, and prolongs the duration of analgesia and reduces the need for morphine 24 hours after the surgery.
Abstract: Background Regional anesthetic techniques are the primary analgesic techniques in breast cancer surgery. Novel techniques include the pectoralis (PECS) block and the erector spinae plane (ESP) block. Objectives This study compared the analgesic efficacy of ultrasound-guided ESP and PECS-II blocks in patients undergoing unilateral modified radical mastectomy (MRM). Methods The current prospective randomized controlled trial investigated 60 females scheduled for unilateral MRM under general anesthesia. The participants were randomized into two groups, namely a single-shot ESP block (n = 30) and a PECS-II block (n = 30). The ESP block was conducted at the level T4 using an in-plane approach. A volume of 20 ml of bupivacaine 0.25% was administered in both blocks. The outcome measures were total morphine consumption, analgesia duration, postoperative pain intensity, and nausea and vomiting. Results More ESP participants required rescue morphine analgesia than those in the PECS group (P = 0.028). The ESP group showed significantly higher total morphine consumption (P = 0.005) and a shorter time to request analgesia (P = 0.003). Pain intensity was higher in the ESP group 1, 2, and 6 hours after the surgery. Conclusions The PECS-II block is more effective in postoperative pain control after breast cancer surgery than the ESP block. It also prolongs the duration of analgesia and reduces the need for morphine 24 hours after the surgery.
2 citations
TL;DR: In inhaled anesthesia and opioids may contribute to a pro-tumor metastasis environment also known as cancer propagation; whereas propofol and COX inhibitors may provide a better alternative to reduce cancer recurrence and propagation.
Abstract: The potential for cancer cells to grow and to metastasize depends on complex interactions between inflammatory signals and pathways, immune cells, and elements of the stromal tissue in which they invade. Related to the nature of many cancers, the probability of recurrence can potentially be quite high for some patients. Immunology, lifestyle modifications, timing of disease, genetics, age, gender, and race are only a handful of ways the likelihood of cancer recurrence can be influenced. The quantity, or density, of certain immunological cells or factors, plays a role in the propagation of cancer cells. Opioids are often used in cancer patients for acute postoperative and chronic pain management. While they can produce significant pain relief, the type of analgesic utilized is important, as it may influence cancer propagation. In this regard, certain opioids have been found to increase T regulatory cells while suppressing NK cell function. Morphine may promote tumor neovascularization and expansion. Fentanyl administration significantly diminishes NK-cells and CD8+ cytotoxic T-cells. In a recent meta-analysis, propofol-based anesthesia improved both cancer-free survival and overall survival. COX inhibitors have also shown promise in persevering cancer immune function, as in literature involving ketorolac and celecoxib. In summary, inhaled anesthesia and opioids may contribute to a pro-tumor metastasis environment also known as cancer propagation; whereas propofol and COX inhibitors may provide a better alternative to reduce cancer recurrence and propagation.
2 citations
TL;DR: IVCCI and IJVCI are efficacious and reliable tools in predicting PSAH in pregnant ladies undergoing cesarean section, with a slight superiority for IVCCI regarding specificity and accuracy.
Abstract: Background Post spinal anesthesia hypotension (PSAH) is frequently encountered in anesthetic practice, especially during cesarean section. Ultrasound is a safe and easy technique for hemodynamic monitoring. Objectives This study was conducted to assess the efficacy of pre-operative inferior vena cava collapsibility index (IVCCI) and internal jugular vein collapsibility index (IJVCI) in predicting PSAH. Methods This cross-sectional blinded study included 55 pregnant females prepared for elective cesarean section. They were divided into two groups based on the incidence of PSAH: (1) cases with PSAH (26 cases); and (2) cases without PSAH (29 cases). All the cases underwent ultrasound-guided measurement of IVCCI and IJVCI. The efficacy of these parameters was assessed in predicting PSAH. Results Cases in both groups expressed non-significant differences regarding demographic data. However, IVCCI had mean values of 38.27 and 23.97%, while IJVCCI had mean values of 46.50 and 33.41%, respectively, in cases with and without PSAH. For IVCCI, using a cut-off point of 33% had sensitivity and specificity (84.6 and 93.1%, respectively) for predicting PSAH, with a diagnostic accuracy of 89.1%. IJVCI had sensitivity and specificity of 84.6 and 82.8%, respectively, for predicting the same complication using a cut-off value of 38.5%. Conclusion IVCCI and IJVCI are efficacious and reliable tools in predicting PSAH in pregnant ladies undergoing cesarean section, with a slight superiority for IVCCI regarding specificity and accuracy.
2 citations
TL;DR: The administration of 8 mg IP dexamethasone was associated with significantly reduced pain and severity of nausea, but not PONV, after laparoscopic cholecystectomy.
Abstract: Background Despite all of the benefits provided by laparoscopic cholecystectomy, such as rapid recovery and shorter hospital stay for patients, the incidence of postoperative nausea and vomiting (PONV) and postoperative pain (POP) still remains high. Objectives This study was designed to compare the effects of intraperitoneal (IP) and intravenous (IV) dexamethasone on the reduction of PONV and POP. Methods This prospective, randomized, double-blind clinical trial was conducted on a study population of 86 adult patients who were scheduled for laparoscopic cholecystectomy with the American Society of Anesthesiologists class I-II. The patients were randomized into three groups, namely IP dexamethasone (n = 29), IV dexamethasone (n = 29), and control (n = 28) groups. The patients were followed for clinical outcomes, including PONV, POP, and consumption of antiemetics, and their hemodynamic status during the first 24 hours after the surgery. Results In the first 24 hours after the operation, no significant differences were observed in nausea (P = 0.41) and vomiting (P = 0.38) between the IP and IV dexamethasone groups. However, there was a lower severity of nausea in the IP group (P = 0.001). Additionally, the visual analog scale score representing POP was significantly reduced in the IP group (P = 0.02). No significant differences in the hemodynamic status were observed after the operation between all the three groups. Conclusions The administration of 8 mg IP dexamethasone was associated with significantly reduced pain and severity of nausea, but not PONV, after laparoscopic cholecystectomy.
2 citations
TL;DR: In this paper , the effect of fentanyl and remifentanil on the QT interval in patients undergoing intubation by the rapid method in 2020 was compared, and the results showed that the rate of QTs interval changes during three different measurements increased in both groups of patients.
Abstract: Background One of the complications of laryngoscopy is cardiac dysrhythmia due to an increased QT interval. Objectives This study aimed to compare the effect of fentanyl and remifentanil on QTc interval in patients undergoing intubation by the rapid method in 2020. Methods In this study, 50 patients without a history of heart disease and without a history of drug use who were candidates for rapid intubation in the emergency department were selected and divided into two groups. Before the injection of intubation drugs, a baseline ECG was obtained from the patient and then randomly assigned to one group of patients with 2 μg/kg fentanyl and the other group with 1 μg/kg remifentanil. Other intubation drugs, including lidocaine, etomidate, and succinylcholine, were fixed in both groups. Immediately after drug injection and immediately after laryngoscopy, ECG was prepared from patients, and the QT interval was calculated. Results In group comparison, changes in QT values during the studied time were statistically significant (P = 0.004). However, in the comparison between groups, there was no statistically significant difference between the two groups receiving fentanyl and remifentanil (P = 0.235). The results showed that the rate of QT interval changes during three different measurements increased in both groups of patients receiving fentanyl and remifentanil. Conclusions In the present study, in comparing the QT interval, there was a statistically significant difference between the two groups receiving fentanyl and remifentanil at any of the studied times. Therefore, fentanyl and remifentanil during endotracheal intubation did not have a statistically and clinically significant effect on the QT distance of patients' ECG, and the administration of the above two drugs during intubation was safe.
2 citations
TL;DR: In this paper , the authors considered the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks.
Abstract: Due to the COVID-19 pandemic, the demand for blood products may decrease as the health care system shifts toward treating the increased number of patients afflicted with COVID-19 and delaying selective surgeries and emergency procedures. One of the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks. This happens due to the limitations of attendance of donors in blood centers, lack of awareness, misinformation, fear of being infected while donating blood, and restricting the freedom of blood collection teams to attend public places. Blood transfusion services should be prepared and well-responded in a timely manner. In this regard, appropriate use of blood, diminishing unnecessary transfusions, and implementation of patient blood management (PBM) principles are considered as significant measurements. PBM can help maintain blood supply throughout the crisis and reduce the pressure on blood demand. As a result, blood products can be saved for patients who need it urgently. PBM focuses on the patient, as well as the conditions that make patients transfuse blood, such as blood loss, coagulopathy, platelet dysfunction, and anemia. Thus, the majority of health systems in different countries have made recommendations to the PBM in hospitals.
TL;DR:
Abstract: Over the last several decades, opioid diversion, misuse, and over-prescription have run rampant in the United States. Spinal cord stimulation (SCS) has been FDA approved for treatment for a primary indication of neuropathic limb pain that is resistant to more conservative medical therapy. The disorders qualified for treatment include neuropathic, post-surgical, post-amputation, osteodegenerative, and pain related to vascular disease. Some of the most frequently cited conditions for treatment of SCS include failed back surgery syndrome, complex regional pain syndrome (CRPS) Type I and Type II, and post-herpetic neuralgias. Developments in SCS systems have led to the differentiation between the delivered electromechanical waveform patterns, including tonic, burst, and high-frequency. Burst SCS mitigates traditional paresthesia due to expedited action potential and offers improved pain relief. Burst SCS has been shown in available studies to be non-inferior to the traditional SCS, which can cause pain paresthesia in patients who already have chronic pain. Burst SCS does not seem to cause or need the paresthesia seen in traditional SCS, making SCS not tolerable to patients. Moreover, some studies suggest that burst SCS may decrease opioid consumption in patients with chronic pain. This can make burst SCS an extremely useful tool in the battle against chronic pain and the raging opioid epidemic. As of now, more research needs to be performed to further delineate the effectiveness and long-term safety of this device.
TL;DR: Interventional, nuclear medicine, radiotherapy, and mini-invasive techniques can be safe and effective for relieving pain and modifying health-related QoL in BM patients.
Abstract: Context Bone metastasis (BM) is a frequent complication of cancer, representing the third most common site of secondary spread in solid cancers behind the lung and liver. Bone metastasis is found in up to 90% of prostate and breast cancer patients. They can cause significant complications, such as pathological fractures and paralysis of the spine, which decrease daily functioning and quality of life (QoL) and worsen prognosis. The growing life expectancy of cancer patients due to improvements in systemic therapies may further increase BM's eventuality and clinical burden in cancer patients. Evidence Acquisition Four physicians from five different specialties were interviewed and resumed the most relevant literature of the last 20 years focusing on pain treatment in BM patients. Results Treatment for BM ideally involves various types of specialists and assessments. The disease status and patient background should be considered, requiring holistic care and expertise from various medical specialties. Conclusions Interventional, nuclear medicine, radiotherapy, and mini-invasive techniques can be safe and effective for relieving pain and modifying health-related QoL in BM patients.
TL;DR: Novel preparations of local anesthetics show great promise in terms of the ability to prolong the duration of single injection PNBs, and these formulations could be the future of pain management if ongoing research continues to prove positive effects and low side effect profiles.
Abstract: The treatment of pain, both acute and chronic, has been a focus of medicine for generations. Physicians have tried to develop novel ways to effectively manage pain in surgical and post-surgical settings. One intervention demonstrating efficacy is nerve blocks. Single-injection peripheral nerve blocks (PNBs) are usually preferred over continuous PNBs, since they are not associated with longer lengths of stay. The challenge of single injection PNBs is their length of duration, which at present is a major limitation. Novel preparations of local anesthetics have also been studied, and these new preparations could allow for extended duration of action of anesthetics. An emerging preparation of bupivacaine, exparel, uses a multivesicular liposomal delivery system which releases medication in a steady, controlled manner. Another extended-release local anesthetic, HTX-011, consists of a combination of bupivacaine and low-dose meloxicam. Tetrodotoxin, a naturally occurring reversible site 1 sodium channel toxin derived from pufferfish and shellfish, has shown the potential to block conduction of isolated nerves. Neosaxitoxin is a more potent reversible site 1 sodium channel toxin also found in shellfish that can also block nerve conduction. These novel formulations show great promise in terms of the ability to prolong the duration of single injection PNBs. This field is still currently in development, and more researchers will need to be done to ensure the efficacy and safety of these novel formulations. These formulations could be the future of pain management if ongoing research continues to prove positive effects and low side effect profiles.
TL;DR: In this article , the effects of ketofol, dexmedetomidine, and isofol in anesthesia of candidates for Dilatation and curettage (D&C) is compared.
Abstract: Dilatation and curettage (D & C) is one of the relatively common surgeries among women. Familiarity with the analgesics, along with their different uses and specific characteristics, can help to determine the best and most appropriate drug to control pain in the patients.This study aimed to compare the effects of ketofol, dexmedetomidine, and isofol in anesthesia of candidates for D & C.In this double-blind clinical trial, 150 candidates for D & C surgeries with ASA class 1 and 2 were included. Patients were randomly divided into three groups. The first group received ketamine + propofol, the second group received dexmedetomidine, and the third group received isofol (isoflurane + propofol). Any hemodynamic changes or respiratory disorders, including apnea or hypoventilation, drop in the level of blood oxygen saturation, and the need for respiratory support, were recorded and compared.Hypoventilation was observed in 47 patients in isofol group, 18 in the dexmedetomidine group, and 42 in ketofol group. Also, 48 patients in the isofol group, eight in the dexmedetomidine group, and 33 in the ketofol group experienced apnea. Moreover, 17 patients in the dexmedetomidine group, 35 in the ketofol group, and eight in the isofol group experienced bradycardia. The rate of bradycardia was significantly higher in the dexmedetomidine group (70%) compared to the other two groups, and the rate of hypotension was significantly higher in the isofol group (P = 0.001).According to the results, dexmedetomidine was associated with fewer complications during general anesthesia in D & C surgery.
TL;DR: The ilioinguinal and iliohypogastric nerve block is efficient and safe for managing postoperative pain following cesarean section operations and is associated with significant improvement of acute and chronic pain after such operations.
Abstract: Background There is an increasing cesarean section (CS) rate in Egypt. Multiple methods are used to manage pain after CS. Objectives This study aimed to assess the effect of ultrasound-guided bilateral ilioinguinal and iliohypogastric nerve block on pain reduction after CS. Methods We classified 64 cases of elective CS into two equal groups. The block group underwent the nerve block, and the control group did not. Postoperative pain, morphine consumption, time to analgesic request, and complications were compared between the two groups. Results No significant difference was detected between the two groups regarding patient characteristics or operation duration. However, pain scores during rest and movement were significantly lower in the block group than in controls, especially within the first 12 hours following the operation. Morphine consumption was significantly lower in the block group (4.53 ± 1.456) in group B vs. (8.87 ± 2.013) in group C with P-value < 0.001. Time to the first rescue analgesia was significantly longer in the intervention group than in the other group (12.25 vs. 3.81 hours). Pruritis and nausea incidence was significantly higher in controls than in the block group. The incidence of chronic postoperative pain was significantly lower in the block group. Conclusions The ilioinguinal and iliohypogastric nerve block is efficient and safe for managing postoperative pain following CS. It is associated with significant improvement of acute and chronic pain after such operations.
TL;DR: The increase of MMP-2-containing gangliocytes one month after PRF procedures highlights active neural cell proliferation in spinal ganglia of the lumbar region, indicating neural remodeling and regeneration.
Abstract: Background Pulsed radiofrequency (PRF) has been used for the treatment of chronic lumbar radicular pain and other chronic pain states. The dorsal root ganglion (DRG) consists of primary afferent somatic and visceral nerve cell bodies that transduce sensory signals from the periphery to the central part of the nervous system. It is a very important part of acute nociception, as well as the development and maintenance of chronic pain. Methods A total of seven domestic pigs were investigated. All pigs underwent a PRF procedure while under general anesthesia and with X-ray imaging. Four lumbar DRGs were randomly treated. We used the opposite side of the DRGs as controls. The lumbar region of the spine was placed in 10% formaldehyde for one month. After this fixation, DRG samples were prepared for slide analysis. Results Nestin (Nes, code-Nr. AB 5968, dilution 1:250, rabbit, Abcam, United Kingdom) and matrix metallopeptidase 2 (MMP-2, code-Nr. DUB 03, dilution 1:100, goat) expressions were detected by immunohistochemical staining. The cell numbers with Nes (28.4 ± 3.3 vs. 16.1 ± 3.4; P < 0.05) and MMP-2 (26.2 ± 3.2 vs. 14.1 ± 2.3; P < 0.05) expressions were larger on the PRF side compared to the control side. The glial cells in the spinal ganglia on both sides showed immunoreactivity. Conclusions The increase of MMP-2-containing gangliocytes one month after PRF procedures highlights active neural cell proliferation. Increased Nes factor expression in spinal gangliocytes of the lumbar region indicates neural remodeling and regeneration.
TL;DR: In this article , the authors evaluated preoperative dexmedetomidine nebulization on the hemodynamic response arising from laryngoscopy/intubation, hemodynamics, analgesic consumption, and postoperative sore throat.
Abstract: Background Nebulized dexmedetomidine has been used for procedural sedation and allaying separation anxiety in children. Literature regarding its use in the attenuation of laryngoscopy and intubation response via the nebulized route is scarce. We evaluated preoperative dexmedetomidine nebulization on the hemodynamic response arising from laryngoscopy/intubation, hemodynamics, analgesic consumption, and postoperative sore throat. Objectives The primary objective was to evaluate/compare the hemodynamic effects of preoperative intravenous and nebulized dexmedetomidine on laryngoscopy/intubation and compare the efficacy of the two routes in blunting the sympathoadrenal response. The secondary objective was to evaluate their effects on intraoperative analgesic consumption and incidence and sore throat postoperatively. Methods 120 ASA I & II adult patients undergoing elective surgeries requiring tracheal intubation were randomized to receive intravenous dexmedetomidine (1 µg/kg over 10 minutes) and nebulized dexmedetomidine (1 µg/kg in 3 - 4 mL of 0.9% saline), 30 min before anesthesia induction. Heart rate and non-invasive blood pressure were monitored for 10 min following laryngoscopy and then throughout the surgery. Intraoperative analgesic consumption, postoperative sore throat, and recovery from anesthesia were assessed. Results No significant hemodynamic difference was found between the two groups till three minutes. Then, the difference turned significant owing to a greater fall in the heart rate and mean arterial pressure in the intravenous group. Nebulized dexmedetomidine exhibited a lesser tendency of hypo/hypertension and brady/tachycardia, while hemodynamics was more stable. There was lesser sore throat and sedation in the nebulized group. Intraoperative analgesic and propofol consumption was comparable between the two groups. Conclusions Nebulized dexmedetomidine attenuated laryngoscopy and intubation response, although to a lesser extent than the intravenous group in equivalent doses. However, the nebulized route provided greater hemodynamic stability in the intraoperative period and lesser sedation/sore throat postoperatively without an increase in adverse effects. Nebulized dexmedetomidine may provide a more holistic and viable alternative in patients who poorly tolerate hypotension, bradycardia, and sedation.
TL;DR: In this paper , the diagnostic accuracy of combined Mallampati and Wilson score in detecting difficult intubation in obese patients undergoing surgery by taking the Cormack-Lehane grading on direct laryngoscopy and intra-tubation as the gold standard was determined.
Abstract: Airway protection during anesthesia is often the primary concern of anesthetists when working with obese patients and always is a difficult task due to increased exposure to harmful effects of apnea, hypoxia, and impaired respiratory mechanics.The primary goal of this research was to determine the diagnostic accuracy of combined Mallampati and Wilson score in detecting difficult intubation in obese patients undergoing surgery by taking the Cormack-Lehane grading on direct laryngoscopy and intubation as the gold standard.This descriptive cross-sectional study was done in 300 obese patients with BMI > 29.9 kg/m2. Modified Mallampati and Wilson score was recorded preoperatively for each patient in the sitting position by the primary investigator. Endotracheal intubation grades were also recorded, and grades IIb, III, and IV were regarded as difficult intubation according to the Cormack-Lehane intubation classification.The mean age was 46.76 ± 15.57 years. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the combined Mallampati and Wilson score for detecting difficult laryngoscopy and difficult intubation were 75.0, 98.8, 92.9, 95.0, and 94.6%, respectively.Combined Mallampatti and Wilson score is highly accurate in the initial diagnostic workup of obese patients at risk of difficult intubation. It is easy to calculate and lower the risk of intubation-related complications and failure.
TL;DR: If low tidal volumes are used during adult laparoscopic bariatric surgery, mechanical ventilation with PC mode is not superior to VC mode, and there was no significant difference between the two ventilation modes in pH, PaCO2, PaO2,PaO2/FIO2, dead space volume, and D (A-a) O2 at different time intervals.
Abstract: Background The number of patients with obesity undergoing various surgeries is increasing annually, and ventilation problems are highly prevalent in these patients. Objectives We aimed to evaluate ventilation effectiveness with pressure-controlled (PC) and volume-controlled (VC) ventilation modes during laparoscopic bariatric surgery. Methods In this open-label randomized crossover clinical trial, 40 adult patients with morbid obesity candidates for laparoscopic bariatric surgery were assigned to VC-PC or PC-VC groups. Each patient received both ventilation modes sequentially for 15 min during laparoscopic surgery in a random sequence. Every 5 min, exhaled tidal volume, peak and mean airway pressure, oxygen saturation, heart rate, mean arterial pressure, and end-tidal CO2 were recorded. Blood gas analysis was done at the end of 15 min. Dynamic compliance, PaO2/FiO2 ratio, P (A-a) O2 gradient, respiratory dead space, and PaCO2-ETCO2 gradient were calculated according to the obtained results. Results The study included 40 patients with a mean age of 35.13 ± 9.06 years. There were no significant differences in peak and mean airway pressure, dynamic compliance, and hemodynamic parameters (P > 0.05). There was no significant difference between the two ventilation modes in pH, PaCO2, PaO2, PaO2/FIO2, dead space volume, and D (A-a) O2 at different time intervals (P > 0.05). Conclusions If low tidal volumes are used during adult laparoscopic bariatric surgery, mechanical ventilation with PC mode is not superior to VC mode.
TL;DR: In this article , the quadratus lumborum (QL) block, also known as the abdominal truncal block, was developed to provide visceral and somatic analgesia during abdominal procedures.
Abstract: Background The quadratus lumborum (QL) block, also known as the abdominal truncal block, was developed to provide visceral and somatic analgesia during abdominal procedures. Objectives This study aimed to assess pain alleviation, the incidence of complications in lower abdominal procedures, and hemodynamic stability between the caudal block and ultrasound-guided QL block. Methods Fifty-two patients aged 1 to 7 years old from both genders scheduled for unilateral lower abdominal surgery were randomly assigned to 2 study groups: group QL, unilateral QL block (n = 26), and group C, caudal block (n = 26). In group C, children received caudal block. In group QL, an ultrasound-guided QL block was performed. The time to first rescue analgesia was evaluated as a primary outcome. The quality of analgesia was determined using the face, legs, activity, cry, consolability scale (FLACC scale), hemodynamic parameters, and incidence of complications because hemodynamic instability was recorded under ultrasound guidance. Signs of local anesthetics toxicity and the parents’ satisfaction were secondary outcomes. Results The time until the first demand for analgesia postoperatively was statistically longer in group QL compared to group C. A non-significant difference was observed between the 2 groups (P > 0.05) regarding age, weight, gender, duration of surgery, type of surgery, FLACC scale, and hemodynamics (SBP, systolic blood pressure), except at 30 minutes, which was significant in QL block. Also, a non-significant difference was observed in the severity of postoperative pain up to 1 day postoperatively. Group QL showed more satisfaction than group C. No intraoperative complications were detected. Conclusions Compared to caudal block, QL block produced sustained and adequate analgesia time postoperatively, with higher satisfaction.
TL;DR: In this paper , the authors proposed a novel concept for categorizing patients with low back pain (LBP) and suggested strategies for improving patient outcomes by stratifying patients according to the etiology.
Abstract: Low back pain (LBP) is the leading cause of pain and debility worldwide and the most frequent reason for work-related disability. Global expenditures related to LBP are staggering and amount to billions of dollars each year in the United States alone. Yet, despite the considerable healthcare resources consumed, the care provided to patients with LBP has regularly been cited as both ineffective and exorbitant. Among the myriad reasons for this suboptimal care, the current approach to evaluation and management of patients with LBP is a likely contributor and is hitherto un-investigated. Following the current methodology, over 90% of patients with LBP are provided with no specific diagnosis, are managed inconsistently, and receive no express preventative care. We believed that this approach added costs and promoted chronic unresolved pain and disability. This narrative review highlights problems with the current methodology, proposes a novel concept for categorizing patients with LBP, and recommends strategies for improvement. Stratifying patients according to the etiology, in lieu of the prospects for morbidity, the strategy proposed in this article may help ascertain the cause of patient’s LBP early, consolidate treatments, permit timely preventative measures, and, as a result, may improve patient outcomes.
TL;DR: Investigating the relationship between depression and pain anxiety with pain catastrophizing in patients with coronavirus disease 2019 found that rumination, magnification, and helplessness could predict the patients’ depression and explain 13.6% of depression changes.
Abstract: Background This study aimed to investigate the relationship between depression and pain anxiety with pain catastrophizing in patients with coronavirus disease 2019 (COVID-19). Methods In this descriptive, correlational study, 180 patients with COVID-19 in Akhtar and Imam Hossein hospitals in Tehran, Iran, were included from March 2019 to April 2020. All participants completed three questionnaires, including the Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale (PASS), and Beck’s Depression Inventory (BDI). The data were analyzed using Pearson correlation coefficient and multivariate regression. Results There was a positive and significant relationship between the dimensions of rumination, magnification, and helplessness with total score of pain catastrophizing, as well as moderate to severe dimensions with total pain anxiety and depression in patients with COVID-19. Conclusions According to the results of regression analysis, pain anxiety based on pain catastrophizing dimensions was statistically significant, so that rumination, magnification, and helplessness could predict pain anxiety and explain a total of 15.1% of changes in pain anxiety. Also, depression was statistically significant based on dimensions of pain catastrophizing, so rumination, magnification, and helplessness could predict the patients’ depression and explain 13.6% of depression changes.
TL;DR: In this article, the authors assessed the difference between the elective and emergent groups regarding the mini-mental state examination (MMSE), hemodynamic effects such as mean blood pressure (MBP), and heart rate (HR).
Abstract: Background Postoperative cognitive dysfunction (POCD) following cesarean section (CS) is a growing and underestimated problem with unknown mechanisms. Studies suggest that general anesthesia (GA) plays a role in the development of early POCD. Objectives This study aimed to assess the incidence of early POCD after elective and emergent CS under GA. Methods We assessed the difference between the elective and emergent groups regarding the mini-mental state examination (MMSE), hemodynamic effects such as mean blood pressure (MBP), and heart rate (HR). Paired t-test was applied for intragroup comparison, and Student’s t-test (or Mann–Whitney U test, as appropriate) for intergroup comparison. Results MMSE one hour after the operation was significantly lower than preoperative MMSE in the emergent group, and the MMSE tended to return to normal values faster in the elective than in the emergent group. Moreover, we found a significantly lower MBP and higher HR (at 15, 30, and 45 minutes) in both groups compared to preoperative values. Regarding intergroup comparison, MBP (at 30 minutes) significantly decreased in the elective group compared to the emergent group. Conclusions There was a significantly lower POCD, especially at the first hour postoperatively, in the elective CS than in the emergent CS. Elective CS might have a positive effect on the women’s health as a mode of delivery.
TL;DR: In this article , the effect of propofol and ketamine on hemodynamic indices and cerebral oxygenation results in children undergoing cardiac catheterization was compared with a comparison between the two drugs.
Abstract: Background Propofol and ketamine are widely used in the induction and maintenance of anesthesia and sedation with different cardiovascular and respiratory effects. In cardiac anesthesia (including pediatric cardiac catheterization), due to the high risk of neurologic complications, cerebral oximetry can effectively monitor cerebral blood oxygen saturation to prevent neurological and respiratory complications. Objectives This study aimed to compare the effect of propofol and ketamine on hemodynamic indices and cerebral oxygenation results in children undergoing cardiac catheterization. Methods This clinical trial study was performed on 48 patients who were candidates for cardiac catheterization by easy and continuous sampling. Patients were randomly divided into 2 groups: ketamine and propofol. In the ketamine group, ketamine was injected at a dose of 1 - 2 mg/kg, and in the propofol group, propofol was injected at a dose of 0.5 - 1.5 mg/kg. In both groups, incremental doses were repeated as needed. The hemodynamic indices, including blood pressure, heart rate, and peripheral SpO2, were recorded. Cerebral regional oxygen saturation (RSO2) was recorded using infrared spectroscopic sensors. Data were analyzed using chi-square, independent t-test, paired t-test, and 1-way analysis of variance (ANOVA). Results The results showed that all demographic characteristics of patients and also the mean duration of catheterization were homogeneous between the 2 groups. Hemodynamic indices (such as systolic, diastolic, and mean arterial blood pressure) did not show a significant difference between the 2 groups; however, in the ketamine group compared to the propofol group, the heart rate was significantly higher, and mean RSO2 was lower (P = 0.023). Conclusions Propofol has fewer complications than ketamine and is a good drug for sedating children undergoing cardiac catheterization.
TL;DR: A depth view (CLO or lateral) is always used by only 45 - 60% of the respondents and CLO view has been rapidly adopted in clinical practice for SCS lead insertion and direct cervicothoracic and upper thoracic is the preferred approach for cervical lead placement by the majority.
Abstract: Background Spinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. The critical part of this technique is safe access to the epidural space for lead placement. There have been innovations in radiological views, improving access to the epidural space. Objectives This study analyzes the adoption of these technical advantages in daily practice Methods We conducted a survey of members in the Spine Intervention Society and American Society of Regional Anesthesia in regard to the practice patterns in SCS therapy. Here we present our findings regarding the use of contralateral oblique (CLO) and lateral views as well direct upper thoracic or cervicothoracic access for SCS lead insertion Results A total of 195 unique responses were received between March 20, 2020 and June 26, 2020. Forty-five percent of respondents “always used” the lateral view technique while 15% “always used” CLO view for SCS lead insertion. Overall, sixty-five percent of respondents used the CLO view with varying frequency. Cervical and upper thoracic approach for cervical SCS lead placement is always or often used by 66.8% of the respondents. Conclusions A depth view (CLO or lateral) is always used by only 45 - 60% of the respondents and CLO view has been rapidly adopted in clinical practice for SCS lead insertion. Direct cervicothoracic and upper thoracic is the preferred approach for cervical lead placement by the majority.
TL;DR: An opioid-free protocol of general anesthesia, using a mixture of dexmedetomidine, ketamine, and lidocaine, did not seem to have a negative impact on postoperative cognitive function in patients undergoing transurethral urological surgery.
Abstract: Background Postoperative cognitive dysfunction (POCD) is a complication that mainly occurs in adult patients and refers to a new-onset decline in cognitive function after anesthesia and surgery. The literature lacks evidence regarding opioid-free anesthesia and its impact on mental function postoperatively. Objectives The effect of opioid-free anesthesia on POCD following urological surgery has not been previously reported. Accordingly, we present a case series of 15 adult patients undergoing transurethral urological surgery under general anesthesia using an opioid-free protocol with dexmedetomidine, ketamine, and lidocaine. Methods Patients that underwent simple transurethral elective urological procedures under general opioid-free anesthesia were included. This case series is part of a prospective clinical study regarding opioid-free anesthesia and served as a pilot sample. The mini-mental state examination (MMSE) test, performed preoperatively and 12 hours postoperatively, was applied to assess POCD. Results Fifteen patients with a mean age of 68 years old were included in the study. The opioid-free protocol was associated with non-statistically significant changes of the MMSE test after minor urological procedures. Conclusions In our study, an opioid-free protocol of general anesthesia, using a mixture of dexmedetomidine, ketamine, and lidocaine, did not seem to have a negative impact on postoperative cognitive function in patients undergoing transurethral urological surgery. Further studies specifically designed to identify this effect are certainly required to further prove such an effect.
TL;DR: According to the results of this study, nebulized milrinone administration before weaning off cardiopulmonary bypass (CPB) can be accelerated and facilitate weaned off CPB.
Abstract: Background Regardless of the cause, pulmonary hypertension can increase patient complications and mortality. This study compared the effect of nebulized versus intravenous (IV) milrinone on reducing pulmonary arterial pressure in patients with pulmonary hypertension candidates for open-cardiac surgery. Methods This double-blind, randomized clinical trial was performed on 32 patients undergoing elective on-pump cardiac surgery during January 2021-January 2022 in the Cardiac Operating Room of Golestan Hospital, Ahvaz, Iran. Patients were randomly divided into test groups nebulize milrinone (N = 16) and IV milrinone (N = 16). The medication was administered after the cross-clamp of the aorta opening. The outcome variables included hemodynamic data, cardiac output, cardiac index, stroke volume, mean arterial pressure (MAP), central venous pressure, mean pulmonary artery pressure (mPAP), systemic vascular resistance, pulmonary vascular resistance, MAP/mPAP ratio, time until extubation, duration of hospitalization in the Intensive Care Unit (ICU), and duration of hospital stay. Results In the nebulized group, MAP and MAP/mPAP were significantly higher than in the IV milrinone group (P = 0.09 and P < 0.0001, respectively). The time of extubation (P = 0.001), duration of hospitalization in the ICU (P = 0.009), and duration of hospital stay (P = 0.026) in the nebulized milrinone group were significantly shorter than in the IV milrinone group. Conclusions Nebulized milrinone administration before weaning off cardiopulmonary bypass (CPB) can be accelerated and facilitate weaning off CPB. Moreover, despite maintaining MAP, nebulized milrinone significantly reduces mPAP. According to the results of this study, nebulized milrinone is recommended in patients undergoing cardiac surgery with pulmonary hypertension.
TL;DR: This study showed that modifiedTLIP block resulted in lower IL-6 level and NRS 12 hours postoperatively compared to classical TLIP block, and there was no difference in intraoperative hemodynamic, Qnox value, and total postoperative morphine consumption between the two groups.
Abstract: Background Ultrasound (US)-guided classical and modified thoracolumbar interfascial plane (TLIP) blocks are often used to provide adequate analgesia after lumbar spinal surgery. Postoperative pro-inflammatory interleukin 6 (IL-6) blood concentrations after lumbar spine surgery are related to postoperative pain and inflammation. Objectives The purpose of this prospective randomized parallel controlled study was to assess postoperative pain and serum levels of pro-inflammatory IL-6 after posterior lumbar decompression and stabilization surgery with a classical and modified technique of TLIP block. Methods This prospective randomized, single-blinded controlled pilot study was conducted on eight patients who will undergo posterior lumbar decompression and stabilization surgery. After obtaining the ethical approval and an informed consent, all subjects were randomly allocated into the classic TLIP group and the modified TLIP group. Following general anesthesia induction, 20 mL bupivacaine 0.25% was injected on each side in interfascialis plane between m. longissimus and m. iliocostalis in modified TLIP group and between m. multifidus and m. longissimus in classical TLIP group. Intraoperative hemodynamic (blood pressure and heart rate) and noxious stimulation response level (qNOX), postoperative IL-6 level, 24-hour morphine consumption, and numerical rating score were recorded and analyzed. Results The median of IL-6 level was found to be lower in the modified TLIP group 12 hours postoperatively compared to classic TLIP (29.91 (8.56 – 87.61) vs. 46.87 (2.87 – 92.35)). The mean Numerical Rating Scale (NRS) in the modified TLIP block was comparable with the classic TLIP group, although it was lower than the classic TLIP group (2.75 ± 1.5 vs. 3.75 ± 1.7 at 6 hours and 3.5 ± 1.3 vs. 4 ± 1.6 12 hours postoperatively). However, there was no difference in intraoperative hemodynamic, Qnox value, and total postoperative morphine consumption between the two groups. Conclusions Our study showed that modified TLIP block resulted in lower IL-6 level and NRS 12 hours postoperatively compared to classical TLIP block. However, there were no differences in total postoperative morphine consumption between the two groups.
TL;DR: In this article , the authors evaluated the effect of nasal phenylephrine nasal drops on bleeding during and after cleft palate repair surgery in children and found that the use of these drops can significantly reduce bleeding and increase surgeon satisfaction.
Abstract: Background Cleft lip and palate are birth defects due to a lack of proper formation of the lip or mouth. Controlling bleeding during cleft lip and palate surgeries is very important. Objectives This study aimed to evaluate the effect of phenylephrine nasal drops on bleeding during and after cleft palate repair surgery in children. Methods This controlled, randomized, double-blind, clinical trial was performed on 36 children aged 6 months to 2 years with cleft palate who were candidates for repair surgery. Patients were randomly divided into 2 groups of 18 patients. In the intervention group, 0.25% phenylephrine drops were poured into the nostrils, and the same amount of normal saline was poured in the control group. Changes in systolic and diastolic blood pressures, heart rate, bleeding during surgery based on the gauzes used, the volume of blood in the suction canister, and the amount of blood in the field, as well as the surgical field quality and surgeon satisfaction, were evaluated using analysis. Results No statistically significant difference was observed between the 2 groups in terms of age, sex, weight, heart rate, and systolic and diastolic blood pressures. The mean volume of bleeding based on the total weight of gauzes used and suctioned blood during surgery showed a statistically significant difference between the intervention and control groups (P = 0.0016). The surgeon satisfaction in terms of the surgical field quality using a 5-point Likert scale showed a significant difference between the 2 groups (P = 0.0068), as well as more satisfaction in the intervention group according to the Boezaart scale (P = 0.0043). Conclusions It seems that the use of nasal phenylephrine drops in pediatric cleft palate surgeries can significantly reduce bleeding and increase the quality of the operation field. Therefore, nasal phenylephrine drops can be used to control bleeding in this type of surgery.