Effects of opium addiction on level of sensory block in spinal anesthesia with bupivacaine for lower abdomen and limb surgery: a case-control study

Comparing Thoracic Epidural Anaesthesia to Rectus Sheath Catheter Analgesia for Postoperative Pain After Major Abdominal Surgeries: A Systematic Review

Controlling postoperative pain is essential for the greatest recovery following major abdominal surgery. Thoracic epidural analgesia (TEA) has traditionally been considered the preferred method of providing pain relief after major abdominal surgeries. Thoracic epidural analgesia has a wide range of complications, including residual motor blockade, hypotension, urine retention with the need for urinary catheterisation, tethering to infusion pumps, and occasional failure rates. In recent years, rectus sheath catheter (RSC) analgesia has been gaining popularity. The purpose of this review is to compare the effectiveness of TEA and RSC in reducing pain following major abdominal surgeries. Four randomised controlled trials (RCTs) reporting outcomes of the visual analogue scale (VAS) pain score were included according to the set criteria. A total of 351 patients undergoing major abdominal surgery were included in this meta-analysis. There were 176 patients in the TEA group and 175 patients in the RSC group. In the random effect model analysis, there was no significant difference in VAS pain score in 24 hours at rest (standardised mean difference (SMD) -0.46; 95% CI -1.21 to 0.29; z=1.20, P=0.23) and movement (SMD -0.64; 95% CI -1.69 to -0.14; z=1.19, P=0.23) between TEA and RSC. Similarly, there was no significant difference in pain score after 48 hours at rest (SMD -0.14; 95% CI -0.36 to 0.08; z=1.29, P=0.20) or movement (SMD -0.69; 95% CI -2.03 to 0.64; z=1.02, P=0.31). In conclusion, our findings show that there was no significant difference in pain score between TEA and RSC following major abdominal surgery, and we suggest that both approaches can be used effectively according to the choice and expertise available.

Rectus sheath block and emergency midline laparotomy at a hospital in Ethiopia: A prospective observational study

BACKGROUND

Midline laparotomy is associated with severe postoperative pain. Literature showed controversial results regarding the efficacy of the rectus sheath block.

METHODS

This is a prospective cohort study that recruits 30 patients in the rectus sheath block (RSB) group and 30 patients in the multimodal analgesia (MMA) group who underwent emergency midline laparotomy. The RSB was performed by an experienced anesthetist using a land-mark technique. Independent t-test and Mann-Whitney-U test were used for numeric data while Chi-Square or Fisher exact test was used for categorical variables. P-values < 0.05 were considered as statistically significant.

RESULTS

The numeric rating scale score at the recovery was significantly reduced in an RSB group with a p-value of 0.039. Postoperative numeric rating scale scores at 3rd, 6th, 12th, and 24th hours were statistically significantly lower in the RSB group. Postoperative tramadol consumption in 24 h was significantly lower with a p-value of 0.0001 for the rectus sheath group.

CONCLUSIONS

For midline laparotomy, adding a bilateral rectus sheath block at the end of the operation might be an effective postoperative analgesia option.

Evaluating sedative effects of dexmedetomidine and morphine in the patients with opioid use disorder undergoing cataract surgery

BACKGROUND

Considering that patients with opioid dependence are at higher risk of inadequate sedation during operations, and the rescue analgesia in these patients are usually greater than the general population; the aim of this study was comparison of sedation quality of dexmedetomidine and morphine in patients with opioid use disorder undergoing cataract surgery.

METHODS

This clinical trial was conducted on 60 patients with opioid use disorder underwent cataract surgery that were referred to Feiz Hospital, Isfahan, Iran in 2018. Patients were randomly divided into two groups as the dexmedetomidine group started 1 μg/kg dexmedetomidine in 10 minutes before surgery and then continued with 0.5 μg/kg/h while the morphine group received 0.1 mg/kg of morphine before surgery. Sedation score, pain intensity, hemodynamic parameters, analgesic request and side effects were compared in the two groups.

RESULTS

There was no significant differences between groups based on Ramsay score before, during and after surgery (P > 0.05), the pain intensity in the morphine group was significantly lower during the recovery period than dexmedetomidine group, the duration of recovery and sedation in the morphine group was significantly more than the dexmedetomidine group, and nausea and vomiting and eye pain in the morphine group were significantly higher than dexmedetomidine (P < 0.05).

CONCLUSION

Morphine usage was more effective in pain relief than dexmedetomidine in patients with opioid use disorder undergoing cataract surgery, but the complications and recovery time were higher in morphine usage. Also the sedation was similar in both groups.

A Comparison of the Effect of Fractionated and Bolus Dose Injection on Spinal Anesthesia for Lower Limb Surgery: A Randomized Clinical Trial

Background

In previous clinical trials and a small number of studies, the fractional injection of anesthetics led to reduced physiological complications and hemodynamic stability and increased duration of anesthesia.

Objectives

The present study intended to compare the effect of fractionated and bolus dose injection of bupivacaine and fentanyl on spinal anesthesia for lower limb fracture surgeries.

Methods

In this randomized, double-blind clinical trial, 70 patients with lower limb fractures were divided into groups of bolus spinal anesthesia (Group A) and fractional spinal anesthesia (Group B). Group A received a bolus dose of 25 μg fentanyl plus 15 mg bupivacaine 0.5% intrathecally at a rate of 0.2 mL/sec and were laid down in supine position after 45 seconds. In Group B, a half dose of the mixture, i.e., 25 μg fentanyl plus 15 mg bupivacaine 0.5% mixture, was injected intrathecally, and then, the other half was injected after 45 seconds while the needle was still in place. Afterward, the patients were immediately laid down in the supine position. Hemodynamic changes in the sensory and motor blockage parameters were recorded in both groups.

Results

The motor blockage onset time was shorter in Group B compared to Group A (P = 0.026). Moreover, the sensory blockage duration was longer (P = 0.035), and the highest level of sensory blockage was lower (P = 0.008) in Group B compared to Group A.

Conclusions

Fractional spinal anesthesia led to a longer duration and more favorable levels of sensory blockage compared to the bolus method. In addition, hemodynamic changes and complications occurred less frequently following this procedure.

Cerebrospinal Fluid and Spinal Anesthesia Parameters in Healthy Individuals versus Opium-addict Patients during Lower Limb Surgery

Background

Studies have reported lower pain threshold, spinal anesthesia duration, and level of sensory block in addicts compared to non-addict patients undergoing spinal anesthesia for surgery. Moreover, blood gas and cerebrospinal fluid (CSF) were likely to be affected as well. The aim in the present study is to evaluate CSF and spinal parameters in addict versus non-addict patients during lower limb surgery.

Methods

In this case-control study, 22 opium addicts and 22 sex- and age- matched non-addicts undergoing lower limb surgery under spinal anesthesia were included. The CSF parameters, venous blood gas (VBG), and sensory and motor block findings were compared between the groups.

Findings

The addict and non-addict patients were similar regarding CSF and blood gas parameters except higher pH in VBG (7.39 ± 0.06 vs. 7.33 ± 0.11, P = 0.030) and CSF (7.39 ± 0.06 vs. 7.33 ± 0.11, P = 0.030) for addict patients. The addict patients had significantly later onset of sensory block (5.72 ± 1.57 vs. 3.16 ± 0.93 minutes, P < 0.001) and shorter motor block duration (137.72 ± 11.51 vs. 149.09 ± 14.44 minutes, P = 0.006), with no significant difference in the sensory block duration and motor block onset.

Conclusion

Addict patients have delayed onset of sensory block with shorter duration of motor block and lower sensory block level. Among the blood gas and CSF markers, only pH was significantly higher in addict patients, needing further evaluations; however, it seems that addiction has no significant effect on these parameters.

Comparison of Adding Sufentanil and Low-Dose Epinephrine to Bupivacaine in Spinal Anesthesia: A Randomized, Double-Blind, Clinical Trial

Background

Spinal anesthesia, as an effective approach, is widely performed in various surgeries with possible complications. To reduce the side effects, many adjuvants are used to maintain desirable sensory and motor blockades and increase the quality and prolong the analgesia.

Methods

In the current double-blind, randomized clinical trial, 105 participants aged 18 - 60 years with ASA class I or II who were candidate for lower limb surgery were randomly allocated to patients receiving bupivacaine 15 mg + normal saline 1 mL (B group), bupivacaine 15 mg + epinephrine 10 µg (BE group), and bupivacaine 15 mg + sufentanyl 5 µg (BS group). Onset of sensory blockade was determined bilaterally with the pinprick test. The maximum Bromage scale was assessed for the onset of motor blockage. Recovery from sensory and motor blockades was also evaluated. Pain score (visual analogue scale; VAS) was determined for all participants.

Results

Onset of sensory and motor blockades was statistically different among the groups. Intrathecal bupivacaine (the placebo group) had the lowest onset of sensory blockage, whereas the onset of motor blockade was significantly shorter with the administration of sufentanil + epinephrine (P = 0.001) (BS and BE groups). However, epinephrine (BE group) did not significantly prolong sensory and motor blockade. Recovery time from sensory and motor blockade was significantly lower with the bupivacaine alone (the placebo group).

Conclusions

The current study results suggested that the combination of 10 µg epinephrine and 5 µg sufentanil + bupivacaine did not prolong the sensory and motor blockades in spinal anesthesia for lower limb surgery, compared with bupivacaine alone.

The Effect of Dexmedetomidine Prescription on Shivering during Operation in the Spinal Anesthesia Procedures of Selective Orthopedic Surgery of the Lower Limb in Addicted Patients

Background

Shivering during a surgery is common. Recently, Alpha-D-agonist dexmedetomidine has been used to control and prevent shivering during and after surgery. However, the anti-shivering effects of this drug in people are unknown with substance abuse. The purpose of this study was to investigate the anti-shivering effect of this drug in addicted individuals.

Methods

After obtaining the required criteria, the criteria were randomized in 2 groups, dexmedetomidine and normal saline (each group n = 30), and were matched in age and sex. The dexmedetomidine 0.5 mg/kg/h was given to one group and normal saline infusion was given to the other group as a placebo immediately after induction of anesthesia and before surgery for lower limb lesions. During the operation, patients were monitored for shivering as well as vital signs and arterial oxygen saturation. In addition, after surgery, patients were evaluated for clinical side effects.

Results

The results showed that systolic blood pressure was significantly lower in the dexmedetomidine group at 30 minutes to 150 minutes after injection during the operation (P < 0.01). There was no significant difference between the 2 groups at the other times. In intra-group comparisons in both groups, diastolic pressure drop was significantly decreased to 90 minutes after surgery. In general, at other times in each group, diastolic pressure changes were not significant compared to preoperative. In between group comparisons, the mean heart rate was significantly lower in the dexmedetomidine group at 30 minutes and 60 minutes compared to the control group. In addition, at other times, its lower values were not significantly different with the control group. The 2 groups did not show significant differences in the number of breaths per minute or as the intra-group (P > 0.05), although, the average respiratory rate per minute in the dexmedetomidine group was lower. Decreased temperature of the tympanic curvature was significantly lower in the DEX group at 10 and 60 minutes after surgery than the control group (P < 0.001). Arterial oxygen saturation was more than 97% in both groups before and after operation, and no difference was observed between the 2 groups.

Conclusions

Prescribing dexmedetomidine during spinal anesthesia in patients with substance abuse can significantly decrease the incidence of shivering during surgery while not having adverse effects on hemodynamics of patients and can be used as a safe and effective drug for this purpose.

Performance of Local Anesthesia with Lidocaine among Opium Addicts and Non-Addicts; a Case Control Study

INTRODUCTION

Compared to ordinary people, addicts usually have a lower pain threshold. The current work attempts to compare the performance of local analgesia with lidocaine among opium addicts and non-addicts.

METHODS

In this case-control study, opium addicts and healthy patients with skin laceration referring to emergency departments of two educational hospitals were compared regarding the response to local anesthesia with lidocaine, as well as side effects.

RESULTS

197 cases with the mean age of 43.44 ± 20.12 years were studied (72.1% male). 98 (49.8%) cases were addicts and 99 (50.2%) were healthy people. Two groups were similar regarding age (p = 0.281), sex (p = 0.666), and wound size (p = 0.272). The amount of pain reduction 5 (df =1.5, F=0.38, p = 0.88) and 10 (df =1.5, F=0.58, p = 0.72) minutes after lidocaine injection was not different between the groups. Subgroup analysis based on sex and age of patient did not show any differences between the groups (p > 0.1 for all analysis). The mean duration of analgesia was 16.4 ± 5.37 minutes in addicts and 16.95±1.79 in control group (p = 0.334).

CONCLUSION

Lidocaine, as a commonly used local anesthetic agents, does not show different effects in addicts and non-addicts in repairing skin laceration.

Comparing the Effect of Adding Fentanyl, Sufentanil, and Placebo with Intrathecal Bupivacaine on Duration of Analgesia and Complications of Spinal Anesthesia in Patients Undergoing Cesarean Section

Background

Spinal anesthesia is the method of choice for most elective and emergency Cesarean sections. To increase the duration of anesthesia and improve the quality of analgesia during and after surgery, intrathecal opioids, as adjuvant drugs, are used in combination with local anesthetics.

Methods

This was a double-blind clinical trial performed on 99 patients. Women were divided into 3 groups of fentanyl, sufentanil, and placebo. For fentanyl group, 12.5 mg of bupivacaine and 25 micrograms of fentanyl; for sufentanil group, 12.5 mg of bupivacaine and 2.5 micrograms of sufentanil; and for placebo group, 12.5 mg of bupivacaine and a half mL of normal saline were injected in subarachnoid space. The sensory and motor block, hemodynamic status (mean blood pressure and heart rate), and probable complications were assessed.

Results

There was no significant difference between the groups in demographic characteristics. Durations of analgesia were, respectively, 314 ± 42.95, 312.5 ± 34.44, and 116.1 ± 42.24 minutes in the fentanyl, sufentanil, and placebo groups (P = 0.0001). Duration of sensory and motor block was higher in fentanyl and sufentanil groups compared with the placebo group. The highest duration of sensory and motor block was noted in sufentanil group (P = 0.0001). No significant difference was found between the groups in the hemodynamic parameters (P > 0.05). The frequency of itching in the fentanyl group was higher than sufentanil and placebo groups (P = 0.003). Also, shivering was higher in the placebo group compared with other groups (P = 0.036).

Conclusions

According to the results, adding 25 microgram fentanyl or 2.5 microgram sufentanil to intrathecal bupivacaine increased the duration of analgesia and provided hemodynamic stability with no major complication. As administering intrathecal fentanyl had a similar duration of analgesia like sufentanil with faster return of motor block and ambulation, it seems that it is a preferred additive for Cesarean section surgery.

The Analgesic Efficiency of Ultrasound-Guided Rectus Sheath Analgesia Compared with Low Thoracic Epidural Analgesia After Elective Abdominal Surgery with a Midline Incision: A Prospective Randomized Controlled Trial

BACKGROUND

Ultrasound-guided rectus sheath blockade has been described to provide analgesia for midline abdominal incisions. We aimed to compare thoracic epidural analgesia (TEA) and rectus sheath analgesia (RSA) with respect to safety and efficacy.

METHODS

Sixty patients who underwent elective laparotomies through a midline incision were assigned randomly to receive either continuous TEA (TEA group, n = 31) or intermittent RSA (RSA group, n = 29). The number of patients who required analgesia, the time to first request analgesia, the interval and the cumulative morphine doses consumption during 72 hours postoperatively, and pain intensity using visual analog score (VAS) at rest and upon coughing were reported in addition to any side effects related to both techniques or administered drugs.

RESULTS

While 17 (54.84 %) patients were in the TEA group, 25 (86.21%) patients in the RSA group required analgesia postoperatively, P = 0.008. Cumulative morphine consumed during the early 72 hours postoperatively median (interquartile range) = 33 mg (27 - 39 mg), 95% confidence interval (28.63 - 37.37 mg) for the TEA group. While in the RSA group, it was 51 mg (45 - 57 mg), 95% CI (47.4 - 54.6 mg), P < 0.001. The time for the first request of morphine was 256.77 ± 73.45 minutes in the TEA group versus 208.82 ± 64.65 min in the RSA group, P = 0.031. VAS at rest and cough were comparable in both groups at all time points of assessment, P > 0.05. The time to the ambulation was significantly shorter in the RSA group (38.47 ± 12.34 hours) as compared to the TEA group (45.89 ± 8.72 hours), P = 0.009. Sedation scores were significantly higher in the RSA group, only at 12 hours and 24 hours postoperatively than in TEA group, with P = 0.041 and 0.013, respectively. The incidence of other morphine-related side effects, time to pass flatus, and patients satisfaction scores were comparable between both groups.

CONCLUSIONS

Continuous TEA had better opioid sparing effects markedly during the early 72 hours postoperatively than that of intermittent RSA with catheters inserted under real-time ultrasound guidance, both had comparable safety perspectives, and RSA had the advantage of early ambulation. RSA could be used as an effective alternative when TEA could not be employed in patients undergoing laparotomies with an extended midline incision, especially after the first postoperative day.

The effect of low dose fentanyl as a premedication before induction of general anesthesia on the neonatal apgar score in cesarean section delivery: randomized, double-blind controlled trial

BACKGROUND

The administration of opioids before induction of general anesthesia can be considered as a problem in cesarean section. The aim of this study was to compare the effects of intravenous Fentanyl as a premedication before induction of general anesthesia versus placebo on maternal hemodynamic parameters and on the first and fifth minutes Apgar score in the neonates in elective cesarean delivery.

METHODS

This double- blinded, randomized, clinical trial study was conducted in 2014-2015 at Vali-e-Asr hospital, Birjand, Iran. Ninety full term pregnant women undergoing elective cesarean section delivery under general anesthesia were selected. The participants were randomly classified into two groups: The Fentanyl group and the placebo. Iintravenous Fentanyl 1μg/kg was administrated three minutes before anesthesia induction for the Fentanyl group, and 2 milliliter normal saline was administered for the placebo group. Maternal mean arterial pressure, heart rate before the start of anesthesia induction and thirty seconds after intubation were measured. Also, the first and fifth minutes Apgar scores of the neonates were evaluated and recorded by a blinded anesthesiologist. The clinical trial registration number was IRCT2015010320112N3.

RESULTS

Maternal mean arterial pressure was significantly lower in the Fentanyl group than the placebo group after intubation. Heart rate was significantly higher in the placebo group before the start of anesthesia induction and after intubation compared to the Fentanyl group. The first and fifth minutes' Apgar scores of the neonates were not statistically different between the two groups.

CONCLUSION

Administration of 1μg/Kg intravenous Fentanyl before the induction of anesthesia for cesarean section delivery decreases maternal hemodynamic changes after intubation. In addition, it does not have any effect on Apgar scores of the neonate in the 1st and 5th minutes after birth.

The Effects of Nitroglycerine on Pain Control During the Propofol Injection; a Controlled, Double-Blinded, Randomized Clinical Trial

Background:

The use of Propofol often results in pain upon injection, which is sometimes very distressing for patients. Many patients report some degree of pain or discomfort on injection with propofol. Injection-induced pain during induction of anesthesia can result in patient's discomfort.

Objectives:

This study was performed to evaluate the effects of nitroglycerine on pain severity in patients undergoing propofol injection.

Patients and Methods:

In this double-blind randomized clinical trial, 100 patients with ASA class I and II undergoing anesthesia with propofol injection were selected for the study from 2012 to 2013 in Imam Reza training hospital. Patients were randomly assigned to case and control groups and received either 20 μg of nitroglycerine or normal saline as placebo. The severity of injection pain was assessed using a four-point scale. An anesthesiologist observed hemodynamic and local adverse effects.

Results:

The pain severity in nitroglycerine group was significantly lower compared with the placebo group (P < 0.0001). Moreover, the local adverse reactions were observed only in three patients in the placebo group while no patient in the drug group experienced adverse effects (P = 0.242). The systolic blood pressure showed no significant difference between two groups before and after the induction of anesthesia but the diastolic blood pressure and the heart rate was significantly different between study groups.

Conclusions:

Nitroglycerine may be a safe and effective adjuvant therapeutic for pain reduction in patients under propofol injection. Hence, its use for reduction of propofol injection-induced pain is recommended.