Intraoperative administration of methadone reduced postoperative pain and opioid consumption following cadaveric renal transplantation: a randomized controlled trial

Objective: In this randomized clinical trial study, the impact of prophylactic administration of methadone during surgery on postoperative pain and analgesic requirement following cadaveric renal transplantation was assessed. Methods: Ninety patients were randomized to receive either methadone 0.15 mg/kg or 0.15mg/kg morphine after tracheal intubation. Both groups were treated with acetaminophen 1 gr before extubation. Protocol of anesthesia was the same in both groups and the anesthetist was blinded to the study groups. The primary outcome was defined as total opioid consumption during recovery and first day after surgery. Secondary outcomes were pain scores and level of patients’ sedation during the recovery period and first postoperative day as well as opioid-related complications. Results: Data of eighty-five eligible patients were analyzed. The mean pain and sedation scores were lower in the methadone group compared to the morphine group during recovery and the first 24 hours after surgery. The time of first rescue analgesic requirement was later in the methadone group (10.4 vs 6.3 hours). Also, postoperative morphine consumption was significantly less in the methadone group compared to patients receiving morphine (3.5 vs. 6.9 mg; P < 0.001). Conclusion: Intraoperative administration of methadone decreased postoperative pain scores, reduced opioid consumption after surgery and improved level of sedation during the first 24 hours after surgery.

Dexamethasone Treatment in Patients With Severe COVID-19: A Propensity Score-Matched Study

During the coronavirus disease-2019 (COVID-19) pandemic, which was caused by the novel coronavirus, there is an ongoing controversy about the use of corticosteroids. This study aims to investigate the association between Dexamethasone treatment and clinical outcomes in patients with severe COVID-19. In this single-center retrospective cohort study, patients with COVID-19 were enrolled from February 16, 2020, to November 1, 2020. After performing propensity score matching with age, sex, and disease severity. The independent effect of Dexamethasone treatment on in-hospital mortality was evaluated by multivariate proportional hazards regression models. Of 1413 patients with COVID-19 diagnosis, 1172 patients entered the final analysis. 473(40.4%) patients received dexamethasone treatment with a median duration of 6.0[4.0-9.0] days. After matching and adjustment with possible confounders in the multivariate model, administration of dexamethasone significantly increased the survival in severe patients (hazard ratio: 0.25, 95 confidence intervals: 0.16-0.38, P<0.001), but there was no difference in non-severe patients (P:0.888). The administering of dexamethasone was associated with an increased in-hospital survival rate (HR: 0.25 [0.16-0.38]) in severe COVID-19 patients. The survival rate was more significant in severe patients with diabetes mellitus or hypertension after receiving dexamethasone treatment (HR:0.19). On the other hand, patients without severe disease did not benefit from dexamethasone administration.

Association of clinical characteristics, antidiabetic and cardiovascular agents with diabetes mellitus and COVID-19: a 7-month follow-up cohort study

BACKGROUND

The prognostic factors of long-term outcomes in hospitalized patients with diabetes mellitus and COVID-19 are lacking.

METHODS

In this retrospective cohort study, we evaluated patients aged ≥ 18-years-old with the COVID-19 diagnosis who were hospitalized between Feb 20 and Oct 29, 2020, in the Sina Hospital, Tehran, Iran. 1323 patients with COVID-19 entered in the final analysis, of whom 393 (29.7%) patients had diabetes. We followed up patients for incurring in-hospital death, severe COVID-19, in-hospital complications, and 7-month all-cause mortality. By doing univariate analysis, variables with unadjusted P-value < 0.1 in univariate analyses were regarded as the confounders to include in the logistic regression models. We made adjustments for possible clinical (model 1) and both clinical and laboratory (model 2) confounders.

RESULTS

After multivariable regression, it was revealed that preadmission use of sulfonylureas was associated with a borderline increased risk of severity in both models [model 1, OR (95% CI):1.83 (0.91-3.71), P-value: 0.092; model 2, 2.05 (0.87-4.79), P-value: 0.099] and major adverse events (MAE: each of the severe COVID-19, multi-organ damage, or in-hospital mortality) in model 1 [OR (95% CI): 1.86 (0.90-3.87), P-value: 0.094]. Preadmission use of ACEIs/ARBs was associated with borderline increased risk of MAE in the only model 1 [OR (95% CI):1.83 (0.96-3.48), P-value: 0.066].

CONCLUSIONS

Preadmission use of sulfonylureas and ACEIs/ARBs were associated with borderline increased risk of in-hospital adverse outcomes.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-021-00901-4.

Monitoring Temperature in Children Under General Anesthesia: Nasopharynx Versus Carotid Artery Surface

Continuous body temperature monitoring during anesthesia in children is very important. Hypothermia in children may lead to higher morbidity and mortality. Measurement points to detect the temperature of core body are not simply accessible. In this study we measured the skin temperature over the carotid artery and compared it with the nasopharynx. Totally, 84 children of 2-10 years undergoing elective surgery were selected. Temperature over the carotid artery and nasopharynx was measured during anesthesia. Mean temperature of these points was compared which each other, and the effects of age, sex, and weight change of temperature during anesthesia were evaluated. The mean age of patients was 5.4±2.6 years s. 37% of patients were female, and 63% were male. The mean weight was 20±7 kg. The mean duration of surgery was 60.45±6.65 min. The temperature of the skin and nasopharynx was decreased during surgery as after 60 min, the deference between skin over the carotid artery and the nasopharyngeal area was 1° C. The bodyweight has a significant effect on carotid skin temperature in regression model. Skin temperature over the carotid artery, with a simple correction factor of+1° C, provides a viable noninvasive estimate of nasopharyngeal temperature in children during elective surgery with a general anesthetic.

Nasogastric tube insertion in intubated patients with the guide of wire rope: A prospective randomised controlled study

INTRODUCTION

Nasogastric tube (NGT) insertion is sometimes required in intubated patients. NGTs are prone to kink and coil during blind insertion. We hypothesised that wire rope guide-assisted NGT insertion with chin lift can significantly improve the first-attempt success rate over the conventional technique during its insertion in intubated patients.

OBJECTIVE

Mean time to successful insertion of NGT, the failure rate of NGT insertion in the first attempt, the failure rate of NGT insertion in the second attempt and overall failure rate were assessed along with the incidence of any complications.

METHOD

This prospective clinical trial conducted 100 adult patients presenting for abdominal surgery under general anaesthesia. These patients were randomised to an experimental technique of Wire rope guide with chin lift (wire group) or a control technique of head flexion (control group) for insertion of the NGT.

RESULTS

The first-attempt success rate was 98% in wire group compared with 74% in the control group (P = .001). Thus, the first-attempt failure rate was 2% in wire group compared with 26% in the control group (P = .001). The median time required to insert the NGT was significantly shorter in wire group (35.3 ± 4.8 vs 61.5 ± 6.2 seconds, P = .001). The incidences of kinking/coiling, bleeding, and moderate injuries were significantly lower in wire group.

CONCLUSION

The use of rope wire guide for correct positioning of the NGT in intubated patients is less time-consuming with the high first-attempt success rate and lower incidence of procedure-related injuries compared to the conventional method.

Prophylactic Administration of Diphenhydramine/Acetaminophen and Ondansetron Reduced Postoperative Nausea and Vomiting and Pain Following Laparoscopic Sleeve Gastrectomy: a Randomized Controlled Trial

PURPOSE

Postoperative nausea and vomiting (PONV) and pain following bariatric surgery are problematic and affect the outcome of patients. Intraoperative multimodal antiemetic prophylaxis is essential to improve postoperative outcomes. This study investigated the effect of adding diphenhydramine to acetaminophen and ondansetron in reducing postoperative nausea and vomiting and pain following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

Eighty-two patients scheduled for LSG were assigned to receive a single preinduction dose of diphenhydramine 0.4 mg/kg VI (D group) in addition to acetaminophen 1g and ondansetron 4 mg IV at the end of surgery and just acetaminophen 1 g and ondansetron 4 mg IV (C group) in a randomized, double-blind trial. PONV was assessed in recovery and 24 hours after surgery in the ward. Postoperative pain, analgesic requirements, and patients' level of sedation were also assessed.

RESULTS

The PONV rates in the recovery of the D group and the C group were 30% and 56% (P = .001). It also had a more significant reduction in the D group than in the C group in the first 24 h after surgery (40% vs. 66%). The severity of pain score and level of sedation and analgesic requirements was significantly reduced in this period in the D group.

CONCLUSION

Prophylactic diphenhydramine 0.4 mg/kg at the induction of general anesthesia in combination with acetaminophen 1 g and ondansetron 4 mg at the end of surgery reduced the incidence of PONV and postoperative severity of pain in laparoscopic sleeve gastrectomy.

Prophylactic administration of diphenhydramine/paracetamol reduced emergence agitation and postoperative pain following maxillofacial surgeries: a randomized controlled trial

BACKGROUND

Emergence agitation after maxillofacial surgeries is an anxious and problematic complication for the surgeon and anesthesiologist that may lead to self-extubation, haemorrhage, and surgical destruction. In this study, we investigated the effects of preemptive administration of diphenhydramine on emergence agitation and quality of recovery after maxillofacial surgery in adult patients.

METHODS

Eighty-five patients undergoing maxillofacial surgery were randomized into two groups. The diphenhydramine group (Group D, n = 40) received diphenhydramine premedication 0.5 mg/kg before anesthesia induction, while the control group (Group C, n = 40) received volume-matched normal saline as a placebo. Before incision, all patients receive 0.1 mg/kg morphine sulfate slowly intravenously within 5 min. Continuous infusion of remifentanil 0.2 μg/kg/h and inhalation of isoflurane was maintained during the anesthesia period. Paracetamol 1 g was infused 15 min before extubation. We evaluated the incidence of agitation during the extubation period after general anesthesia, hemodynamic parameters, and recovery characteristics during the postoperative period.

RESULTS

During extubation time, the incidence of emergence agitation was lower in Group D than in Group C (16% vs. 49%, P = 0.041). The time from isoflurane discontinuation to extubation (7.7 min in Group D vs. 6.8 min in Group C, P = 0.082) was not different. Grade of cough during emergence, the severity of pain, analgesic requirements, and hemodynamic changes were lower in group D compared with Group C.

CONCLUSIONS

Preemptive administration of diphenhydramine provided smooth emergence from anesthesia. It also improved the quality of recovery after maxillofacial surgery.

TRIAL REGISTRATION NUMBER

This study was registered at http://irct.ir (registration number IRCT20130304012695N3).

The Effect of Intraoperative Ketamine and Magnesium Sulfate on Acute Pain and Opioid Consumption After Spine Surgery

Ketamine and magnesium in brain act as an N-methyl-D-aspartate receptor antagonist that has been shown to be useful in the reduction of acute postoperative pain and analgesic consumption in a variety of surgical interventions. We hypothesized that combination of low dose ketamine and magnesium would reduce early postoperative opiate consumption and analgesic requirement after 6 weeks. This was a randomized, prospective, controlled-placebo trial involving elective and eligible patients undergoing lumbar spine surgery. Seventy patients in the treatment group were administered 0.5 mg/kg intravenous ketamine and 1 gram of magnesium as an intravenous bolus slowly during 3 minute before incision and 0.25 mg/kg/hr ketamine and 0,5 g/hr magnesium intravenous infusion during surgery. Seventy patients in the placebo group received saline of equivalent volume. Patients were observed for48 h postoperatively and followed up at 6 weeks. The primary outcome was 48h morphine consumption. The severity of pain was lower in the intervention group than in the placebo group during 48 hr post-operatively, morphine consumption in this group also decreased significantly during this period. Intraoperative ketamine-magnesium reduces opiate consumption in the 48-h postoperative period. This combination may also reduce pain intensity throughout the postoperative period in this patient population.

Dexmedetomidine Versus Ketamine Combined With Fentanyl for SedationAnalgesia in Colonoscopy Procedures: A Randomized Prospective Study

Abstract- Colonoscopy is a painful, embarrassing and short-term procedure that needs temporary sedation and rapid recovery. The aim of this study was to compare the sedation and analgesia effect and hemodynamic changes due to bolus intravenous injection of dexmedetomidine and ketamine during elective colonoscopy. This clinical trial was conducted on 70 patients aged 20-70 years, candidates for elective colonoscopy, who randomly divided into two equal groups. For all patients 0.03 mg/kg midazolam 10 min before procedure was injected. Fentanyl 1 µ/kg was administrated in both groups 5 min before procedure, and one min before colonoscopy. K group received 0.5 mg/kg ketamine and D group received 1 µ/kg dexmedetomidine. Then, the normal saline infusion was used as maintenance. Fentanyl 25-50 µg was prescribed as the rescue dose if needed during the procedure. Hemodynamic changes, sedation level during procedure, patients and colonoscopists satisfaction were recorded in recovery. The mean heart rate and mean blood pressure was significantly less in the dexmedetomidine group than in the ketamine group. All of the patients in the ketamine group were deep to moderately sedated during colonoscopy, and the amount of fentanyl required in this group is much less than dexmedetomidine group (68.02±25.63 vs 91.45±38.62 µg P-0.003). In terms of satisfaction, only 42% of patients in the dexmedetomidine group were completely satisfied with colonoscopy, while 65% of Ketamine group had complete satisfaction with colonoscopy (P=0.001). The level of colonoscopist satisfaction during colonoscopy was similar in both group, and complete satisfaction was 43%. In patients undergoing colonoscopy, IV bolus injection of dexmedetomidine in comparison with ketamine provides less patients satisfactory and low level of sedation with supplemental multiple doses of fentanyl during the procedure.

Diphenhydramine Definitely Suppresses Fentanyl-Induced Cough During General Anesthesia Induction: A Double-Blind, Randomized, and Placebo-Controlled Study

Fentanyl-induced cough (FIC) is a known complication, and many studies have been conducted to prevent it. The aim of this study was to evaluate the effectiveness of Diphenhydramine as an antihistamine in suppressing of FIC during induction of anesthesia. In a prospective, double-blind, randomized controlled trial, a total of 100 patients, ASA Class I and II, scheduled for elective laparoscopy surgery were randomly assigned into two equally sized groups (n=50). Diphenhydramine diluted with distilled water as 10 mg/ml. Then, patients in Group D, received diphenhydramine 30 mg (3 ml) through peripheral IV line within 1 min and Group C received the same volume normal saline 0.9% as placebo. Two min later, fentanyl 2 µg/kg was administered through the peripheral IV line within 5 sec in all patients. The occurrence and intensity of cough within 2 min after the fentanyl injection were observed and recorded by a resident who was blinded to the study groups. The frequency of PONV, analgesic requirement in the recovery room and as a secondary outcome were recorded. The incidences of FIC were 47% in the control group, and there is no cough in the diphenhydramine group (P=0.02). The frequency of PONV was also reduced in diphenhydramine group (16% vs. 40%) and less number of patients in diphenhydramine group was needed to analgesia in the recovery room (60% vs. 82%). Our study determines that diphenhydramine (30 mg, IV) bolus injection 2 min before fentanyl injection can prevent FIC and PONV and also reduce analgesic requirement inthe recovery room. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(5):316-319.

The Efficacy of Intraoperative Ketamine-Haloperidol for Prevention of Catheter-related Bladder Discomfort After Lumbar Spinal Stenosis Surgery

Objectives

Catheterization of urinary bladder during surgery frequently leads to agitation of the patient in the recovery room, especially in those patients who remain catheterized after gaining consciousness. We hypothesized that administration of a combination of ketamine-haloperidol (KH) before urinary catheterization would reduce the incidence of catheter-related bladder discomfort (CRBD) while reducing some adverse effects of ketamine in the postoperative period.

Methods

A total of 119 male patients who underwent lumbar spinal stenosis surgery were randomized into three groups. The KH group consisted of 39 patients who received KH just before urinary catheterization. The second arm of the study including 40 patients who received pethidine-haloperidol (PH). The control (C) group consisted of 40 patients who received normal saline as a placebo. We sought to determine the incidence and severity of CRBD at arrival in recovery and one, six, and 24 hours after.

Results

The incidence of CRBD upon arrival in the recovery room was 17.9% in the KH group, and 52.5% and 55% in the PH and C groups, respectively. The incidence of CRBD was significantly lower in the KH group at arrival in the recovery room. The severity of CRBD was lower in the KH group at one and six hours of surgery (p < 0.007). There was no significant difference 24 hours after surgery.

Conclusions

Intravenous administration of KH before urinary catheterization effectively decreases the incidence and severity of postoperative CRBD while reducing adverse effects attributed to ketamine.

Half Saline-Bicarbonate Solution as Intraoperative Fluid Replacement Therapy Leads to Less Acidosis and Better Early Renal Function During Deceased-Donor Transplant

OBJECTIVES

Normal saline is the most common crystalloid solution that is used in renal transplant surgery. In this study, our aim was to determine the effects of a combination of half saline and bicarbonate versus normal saline as a routine solution.

MATERIALS AND METHODS

For this double-blind random-ized clinical trial, we enrolled 100 adult patients undergoing kidney transplant. Patients were divided into 2 groups: those who received normal saline and those who received half saline and bicarbonate infusion as fluid replacement therapy during renal transplant. All patients received about 40 mL/kg of crystalloids during surgery. Serial creatinine con-centrations (primary outcomes) were compared between groups at 1, 2, 3, and 7 days after surgery. Urine output (secondary outcome) was compared between groups at recovery and at 6 and 24 hours after surgery. In addition, base excess, chloride, and sodium levels were measured before and 6 hours after surgery. Each liter of half saline-bircarbonate, which is relatively isoosmotic to human plasma, was composed of 70 mEq bicarbonate, 77 mEq chloride, and 147 mEq sodium.

RESULTS

Patients who received half saline-bicarbonate had significantly lower postoperative creatinine levels at all time points than patients who received normal saline (P = .019). Serum chloride and sodium levels (P = .001) were significantly higher and base excess (P = .007) was significantly lower in the normal saline group at 6 hours after transplant. At all time points, urine output levels were significantly higher in the half saline-bicarbonate group (P = .001).

CONCLUSIONS

The use of half saline-bicarbonate was associated with better early graft function compared with normal saline in the first 7 days after transplant.

Preemptive Effect of Intraurethral Instillation of Ketamine-lidocaine Gel on Postoperative Catheter-related Bladder Discomfort after Lumbar Spine Surgery

Background:

Catheter-related bladder discomfort (CRBD) is one of the main reasons of agitation after surgery, leading to urgency and frequency during recovery. Ketamine has been used as an effective drug for reducing the signs and severity of this problem. We hypothesized that intraurethral instillation of ketamine–lidocaine gel before urinary catheterization can reduce the incidence of CRBD in the postoperative period.

Materials and Methods:

A total of 136 male patients, who underwent two-level laminectomy/discectomy were enrolled in this randomized clinical trial. Patients were randomized into the two groups before urinary catheterization. The ketamine group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL (100 mg) ketamine. Patients in control group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL distilled water. The primary outcome was the incidence of CRBD. CRBD was assessed using four-stage criteria when arriving in the recovery room and at 1, 2, and 6 h after surgery. Postsurgical pain and the number of sedatives given and opioid requirement were also the secondary outcomes in this study.

Results:

Intraurethral instillation of ketamine–lidocaine gel reduced the incidence of CRBD at recovery (P < 0.001) along with a reduction in the severity of CRBD (P < 0.05) during the 1^st and 2^nd visit compared with control group. The mean pain intensity score (visual analog scale) and opioid requirement to relieve postsurgical pain were lower in the ketamine group during all the study timepoints from recovery and after transfer to the ward (P < 0.008). A higher rate of sedation (72% vs. 11%) also was seen at recovery period in the ketamine group (P < 0.008).

Conclusion:

Intraurethral instillation of ketamine–lidocaine gel before bladder catheterization is an effective technique for reducing the incidence and severity of postoperative CRBD.

Comparison of Arterial Oxygenation Following Head-Down and Head-Up Laparoscopic Surgery

BACKGROUND

Regarding the role of gas entry in abdomen and cardiorespiratory effects, the ability of anesthesiologists would be challenged in laparoscopic surgeries. Considering few studies in this area and the relevance of the subject, this study was performed to compare the arterial oxygen alterations before operation in comparison with after surgery between laparoscopic cholecystectomy and ovarian cystectomy.

METHODS

In this prospective cohort, 70 consecutive women aged from 20 to 60 years who were candidate for laparoscopic cholecystectomy (n = 35) and ovarian cystectomy (n = 35) with reverse (20 degrees) and direct (30 degrees) Trendelenburg positions, respectively, with ASA class I or II were enrolled. After intubation and before operation, for the first time, the arterial blood gas from radial artery in supine position was obtained for laboratory assessment. Then, the second blood sample was collected from radial artery in supine position and sent to the lab to be assessed with the same device after 30 minutes from surgery termination. The measured variables from arterial blood gas were arterial partial pressure of oxygen (PaO2) and Oxygen saturation (SpO2) alterations.

RESULTS

Total PaO2 was higher in the first measurement. The higher values of PaO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.060) and multivariate analysis (P = 0.654). Furthermore, higher values of SpO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.412) and multivariate analysis (P = 0.984).

CONCLUSIONS

In general, based on the results of this study, the values of PaO2 in cholecystectomy (upward) were not significantly higher than the values in cystectomy (downward) in laparoscopic surgeries when measured 30 minutes after surgery.

Prognostic Value of Hemoglobin Concentration and Graft Vein Blood Oxygenation on Renal Transplant Outcomes

OBJECTIVE

Our objective was to investigate vein blood gas levels in the transplanted kidney during surgery as a predictive factor for delayed graft function after renal transplant.

MATERIALS AND METHODS

Sixty patients with renal transplant were enrolled in our study from January 2015 to January 2016. After vessels were declamped posttransplant, blood samples from the transplanted kidney veins were taken and acidosis and oxygenation in these samples were measured. Patients were classified based on acidosis and oxygenation of grafted vein and also hemoglobin concentration. We compared delayed graft function in recipients with acidosis versus normal pH, hypoxia versus normal oxygenation, and hemoglobin less than 10 g/dL versus more than 10 g/dL.

RESULTS

Of 60 patients, 6 (10%) experienced delayed graft function and needed hemodialysis. All patients needing hemodialysis were in the acidotic and hypoxic patient groups. Five of six recipients with delayed graft function had hemoglobin concentration < 10 g/dL. Hospital stay was significantly longer in patients with hypoxia, acidosis, and anemia.

CONCLUSIONS

Vein blood gas measurements of the grafted renal vein during surgery can be easily obtained and applied as a prognostic factor for delayed graft function.

Comparison Effect of Promethazine/Dexamethasone and Metoclopramide /Dexamethasone on Postoperative Nausea and Vomiting after Laparascopic Gastric Placation: A Randomized Clinical Trial

Background

Laparoscopic gastric plication (LGP) is a technique in the restrictive category of bariatric procedures that reduces the gastric volume and increases intragastric pressure. Nausea and vomiting are the most common complications after this procedure. The goal of this research is to compare the combined effect of promethazine/dexamethasone versus Metoclopramide/ dexamethasone on the prevention of nausea and vomiting after LGP.

Methods

In recovery, the patients were divided into two groups, the Metoclopramide group which was given Metoclopramide 10 mg plus dexamethasone 4 mg/8 hours intravenous for 48 hours, and the promethazine group which was given promethazine 50 mg /12 hours, intramuscular for the first 24 hours and then promethazine 25 mg/12 hours for the next 24 hours plus dexamethasone 4 mg/8 hours intravenous for 48 hours. The frequency of nausea and vomiting, number of reflux episodes, frequency of epigastric fullness, and the duration of walking around q12 hours were recorded in the first 48 hours post-operation.

Results

Eighty patients were enrolled into the study. Promethazine group were found to significantly reduce the incidence of PONV in the first 24 hours compared with the other group (41% vs. 97.5%), relative risk = 0.042 [95% CI = 0.006, 0.299]. The mean numbers of epigastric fullness and severity of epigastria pain were lower in the promethazine group (P = 0.01) and the total opioid requirement was also reduced in promethazine group (32.1 ± 2.6 VS .68.5 ± 4.6 mg). However, the patients in the promethazine group were more sedated, which caused the duration of walking q12 hours in this group to decrease.

Conclusions

In morbidly obese patients undergoing laparoscopic gastric plication, promethazine/dexametasone was more effective than Metoclopramide/dexametasone in preventing and reducing the incidence of nausea, epigastric fullness, and reflux. That combination was also more effective than Metoclopramide in reducing the severity of epigastric pain.

An Assessment of Intubation Skill Training in Novice Anesthesiology Residents of Tehran University of Medical Sciences With the Use of Mannequins

BACKGROUND

The goal of this study was to evaluate the impact of intubation skill training involving the use of mannequins on novice anesthesiology residents in a knowledge, attitudes, and practices designed study in which three different types of evaluation were implemented.

METHODS

All first-year anesthesiology residents (24) of Sina Hospital, affiliated to the Tehran University of Medical Sciences, were invited to participate in an intubating skills training course. The program comprised two theoretical and three practical sessions, lasting a total of 16 hours over four days. Faculty assessment of residents' practices was carried out using the questionnaire results, measured using a Likert scale, as the primary outcome. An improvement in the theoretical knowledge of the novice anesthesiology residents (using the Likert scale) and their attitudes towards the educational course in general (via a multiple choice question examination), were also evaluated.

RESULTS

The mean score following faculty assessment of the residents' practical skills was 4.6 out of 5.0 (92%) [standard deviation (SD) of 0.13]. The mean score with respect to the attitudes of the residents was 4.8 out of 5.0 (96%) (SD of 0.16). The overall mean theoretical score of the residents improved significantly upon completion of the training program (P = 0.001).

CONCLUSIONS

Our results suggest that the personnel in the five participating faculties were highly satisfied with the practical performance of the residents, who were found to hold good attitudes towards the program as a whole.

Combined Ketamine-Tramadol Subcutaneous Wound Infiltration for Multimodal Postoperative Analgesia: A Double-Blinded, Randomized Controlled Trial after Renal Surgery

Background

Pain is an important consideration after renal surgery. A multimodal approach to postoperative pain management could enhance analgesia by risking fewer side effects after surgery.

Objectives

The aim of this study was to evaluate the clinical efficacy of the subcutaneous infiltration of ketamine and tramadol at the incision site to reduce postoperative pain.

Methods

Sixty-four patients between 18 and 80 years old who were scheduled for elective renal surgery were enrolled in a double-blind randomized controlled study. At the end of the surgery, patients were divided into four groups with 16 patients in each group: the saline group, who were treated with 10 mL of saline solution; the K group, who were treated with 1 mg/kg etamine in 10 mL of saline solution; the T group, who were treated with 1 mg/kg tramadol in 10 mL of saline solution; and the K/T group, who were treated with 0.5 mg/kg ketamine with 0.5 mg/kg tramadol in 10 mL of saline solution. In each group, the solution was infiltrated subcutaneously at the incision site. The postoperative pain scores and rescue analgesic consumption of the patients in each group were recorded for 24 hours and compared. The primary goal of the study was to compare the results of patients treated with a combined ketamine and tramadol subcutaneous wound infiltration, patients treated with a tramadol subcutaneous wound infiltration, and patients treated with a ketamine subcutaneous wound infiltration.

Results

Sixty-four patients were enrolled in the study. Pain intensity and cumulative meperidine consumption were significantly lower in the K/T group (27 mg; 95% confidence interval, 25.2 - 53.2) in comparison with the group that received a saline infusion during the first 24 hours after surgery (P < 0.001). The sedation score of the K, T, and K/T groups were significantly higher than the saline group (P < 0.001).

Conclusions

The combined subcutaneous infiltration of ketamine and tramadol at the incision site produces better analgesia and an opioid-sparing effect during the first 24 hours when compared with the control group and the groups that received a subcutaneous infiltration of only ketamine or tramadol.

Multimodal Analgesia With Ketamine or Tramadol in Combination With Intravenous Paracetamol After Renal Surgery

Background

Opioids are generally the preferred analgesic agents during the early postoperative period.

Objectives

The present study was designed to assess and compare the multimodal analgesic effects of ketamine and tramadol in combination with intravenous acetaminophen after renal surgery.

Patients and Methods

This randomized, double-blinded, clinical trial was conducted on 80 consecutive patients undergoing various types of kidney surgeries in Sina hospital in Tehran in 2014 - 2016. After extubation, the patients were randomly assigned to receive intravenous paracetamol (1 gr) plus tramadol (0.7 mg/kg) (PT group) or paracetamol (1 gr) plus ketamine (0.5 mg/kg) (PK group) within ten minutes. Pain severity was assessed by the visual analog scale (VAS), and the level of agitation was assessed by the Ramsey sedation scale (RSS). Morphine consumption was assessed within the first six hours after drug injection, and hemodynamic parameters were assessed at 5, 10, and 20 minutes after infusion, at the time of transfer from recovery to the ward, and also at one and six hours after transfer to the ward.

Results

Postoperative pain scores were significantly lower in the PK group than in the PT group during all study time points. The mean dose of morphine needed at recovery in the PK group was lower compared with the PT group (0.47 ± 0.94 mg versus 1.50 ± 1.35 mg/P = 0.001). The level of agitation based on the RSS score was significantly lower in the PK group than in the PT group at 10 and 20 minutes after drug administration. The total postoperative complication rate in the PK group was lower than in the PT group (20% versus 53.3%, P = 0.007). In this regard, catheter bladder discomfort was more frequent in the PT group than in the PK group (43.3% versus 3.3%, P < 0.001).

Conclusions

The combination of intravenous paracetamol 1 gr and ketamine 0.5 mg/kg resulted in an overall reduction in pain scores, decreased postoperative analgesic requirements, and lower agitation score compared with intravenous paracetamol 1 gr and tramadol 0.7 mg/kg for patients undergoing renal surgery.

Effects of Ropivacaine on Postoperative Pain and Peak Expiratory Flow Rate in Patients Undergoing Percutaneous Nephrolithotomy

BACKGROUND

Postoperative analgesic effects of ropivacaine have been demonstrated in various surgical procedures; however, its beneficial effect on postoperative pain relief and ability to breathe out air in urological surgeries, particularly in local interventions such as percutaneous nephrolithotomy (PCNL), has remained uncertain.

OBJECTIVES

The aim of this study was to assess the efficacy of ropivacaine on postoperative pain severity and peak expiratory flow (PEF) in patients undergoing PCNL procedure.

PATIENTS AND METHODS

This randomized double-blinded clinical trial was performed on 55 consecutive adult patients aged 15 to 60 years who underwent Tubeless PCNL surgery. The patients were randomly assigned to instill 30 mL of ropivacaine 0.2% or 30 mL of isotonic saline with the same protocol. The parameters of visual analogue scale (VAS) (for assessment of pain severity) and PEF (for assessment of ability to breathe out air) were measured 4 and 6 hours after completing the procedure. Moreover, the amounts of opioids or analgesics administered within 6 hours after the operation were recorded.

RESULTS

We found no difference in the mean pain severity score between the case and control groups 4 hours (P = 0.332) and 6 hours (P = 0.830) after the operation. The mean PEF at baseline was similar in case and control groups (P = 0.738). Moreover, no difference was revealed in PEF index 4 hours (P = 0.398) and 6 hours (P = 0.335) after PCNL between the groups. The mean VAS scores 4 hours after the operation slightly decreased 2 hours later (P < 0.001) in the both groups. Moreover, in the both groups, a sudden decrease in PEF index was observed within 4 hours after the operation and increased with a mild gradient for the next 2 hours. No difference was found in the amount of postoperative analgesic used in the both groups.

CONCLUSIONS

Instillation of ropivacaine 0.2% (30 mL) within tubeless PCNL surgery does not have a significant effect on postoperative pain relief and improvement of PEF within 6 hours after the operation.

Analgesic Efficacy of Nephrostomy Tract inFiltration of Bupivacaine and Ketamine after Tubeless Percutaneous Nephrolithotomy: A Prospective Randomized Trial

BACKGROUND

Recently, the use of ketamine as a systemic and local analgesic drug in reducing post-operative pain is studied more frequently.

OBJECTIVES

The aim of the present study was to assess the analgesic efficacy of IV ketamine injection inaddition to nephrostomy tract infiltration of ketamine-bupivacaine on postoperative pain relief after tubeless percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

Patients (n = 100), with renal stone who were candidates for PCNL were randomized to five groups with 20 cases in each: Group C, 10 mL of saline solution was infiltrated into the nephrostomy tract; Group B, 10 mL of 0.25% bupivacaine was infiltrated into the nephrostomy tract; Group BK1, 10 mL of 0.25% bupivacaine plus 0.5 mg/kg ketamine was infiltrated into the nephrostomy tract; Group BK2, 10 mL of 0.25% bupivacaine plus 1.5 mg/kg ketamine was infiltrated into the nephrostomy tract; Group K, 10 mL of saline solution containing 0.5 mg/kg ketamine was intravenously administered. Post-operative pain scores were compared between groups as the primary objective. Comparison of Sedation Scores, rescue analgesic consumption, time to the first rescue analgesics administration, hemodynamic and SpO2 values were regarded as the secondary objective.

RESULTS

Mean VAS scores in the first 30 min and total analgesic consumption in the first 24 h of post-operative period were significantly lower in groups BK1 and BK2 in comparison with the other groups (P < 0.05). Also, time to first rescue analgesics administration was longer in the same groups (P < 0.05).

CONCLUSIONS

Infiltration of ketamine plus bupivacaine provides superior analgesic effects in PCNL surgery compared with other methods.

Comparison of aPTT and CT Parameter of the ROTEM Test to Monitor Heparin Anti-Coagulation Effect in ICU Patients: an Observational Study

Heparin is frequently used in different clinical settings to reduce the coagulating ability of the blood. Because of probable adverse effects owing to heparin therapy and regarding variability of patients' responses to heparin, which make it very unreliable, it seems prudent to monitor meticulously its effects on the human body. There are a lot of laboratory tests to watch its effects on the body for example; aPTT and ROTEM are the most widely used tests that are performed today. We aimed to compare the aPTT test results against changes of CT parameter of the ROTEM test due to heparin administration. This study was conducted on 45 critically ill patients who needed to receive heparin according to their clinical status. All patients received 550 to 1500 unit heparin per hour (on average 17.5 unit heparin per kilogram weight). While the patients were under infusion of heparin, two blood samples (5 ml) were taken from a newly established cubital vein, just five hours after commencement of heparin therapy. One sample was used for aPTT and the other one for ROTEM. The correlation between aPTT and the changes of CT parameter of the ROTEM with heparin dosage and infusion was the primary outcome. The correlation between heparin therapy and the changes of other parameters like MCF, CFT, and a number of platelets were the secondary outcome of the study. The only significant correlation was between changes of CT and aPTT (P=0.000). The other variables were not correlated. Changes of CT parameter of ROTEM test can be used for monitoring of reduced coagulability during heparin infusion instead of aPTT test.

Effects of laparoscopic gastric plication (LGP) in patients with type 2 diabetes, one year follow-up

Background

Obesity is a major risk factor for the development of type 2 diabetes mellitus. Surgery is one of the most effective treatments for morbid obesity. In a prospective cohort study, we examined the effects of Laparoscopic Gastric Plication (LGP) as a new restrictive technique on remission of type 2 diabetes mellitus.

Methods

During six years of study from June 2007 through December 2013, 62 patients who underwent bariatric surgery were recruited for our study to determine the effects of weight loss. Sixty patients with diabetes mellitus type 2 were selected for a one year follow up period. The amount of weight loss, Fasting Blood Sugar (FBS), changes in the lipid profile, HbA1c and blood pressure were assessed during this period. The primary outcomes were safety and the percentage of patients experiencing diabetes remission.

Results

Sixty patients with the mean age of 39.7 ± 12.8 years, ranging from 18 to 62 years, were enrolled in the study for an average 12 months of follow up. The maximal weight loss of 57 kg was achieved at average after six months. FBS significantly decreased during this period, and after one year, remission of diabetes was achieved in 92 % of patients. In five patients, diabetes was controlled with decrease in taking oral medications.

Conclusions

Laparoscopic Gastric Plication (LGP) resulted in significant and sustained weight loss with minimal physiologic changes in gastrointestinal tract and ameliorated blood glucose control of type 2 diabetes in morbid obese patients.

Intrarectal Lidocaine-Diltiazem-Meperidine Gel for Transrectal Ultrasound Guided Prostate Biopsy

Background:

TRUS-guided needle biopsy of the prostate gland is the current standard method used for diagnosis of prostate cancer. Pain control during this procedure is through the use of i.v. sedation or local anaesthetic (LA), depending on clinician preference.

Objectives:

The aim of this study was to evaluate the effectiveness of intrarectal lidocaine, lidocaine-diltiazem and lidocaine-meperidine-diltiazem gel for anesthetizing transrectal ultrasound guided prostate biopsy.

Patients and Methods:

In a randomized double-blind clinical trial, 100 consecutive patients were divided into three groups. The patients received one of the gels before transrectal ultrasound guided prostate needle biopsy: group A, intrarectal and perianal lidocaine, gel 1 g; group B, intrarectal lidocaine gel, 1 g, + perianal diltiazem, 1 g; group C, intrarectal lidocaine gel, 1 g, + meperidine, 25 mg, and perianal diltiazem, 1 g. Visual analog pain scale was used to estimate pain during probe insertion and biopsy. Heart rate and blood pressure during probe insertion and biopsy were recorded too.

Results:

The mean of visual analog pain scale was 4.5 in group A, 3.5 in group B, and 2.0 in group C during probe insertion (P value = 0.01). The mean of visual analog pain scale was 5.1 in group A, 3.5 group B, and 2.5 in group C during biopsy (P value = 0.001). The groups were comparable for patients' age, weight, serum prostate-specific antigen (PSA), and prostate size (P > 0.05). No side effects of meperidine and lidocaine including drowsiness, dizziness, tinnitus and light-headedness or requiring assistance for activity were noted.

Conclusions:

Lidocaine-meperidine-diltiazem gel provides significantly better pain control than lidocaine-diltiazem gel and lidocaine gel alone during transrectal ultrasound guided prostate biopsy and probe insertion. This mixture gel is safe, easy to administer and well accepted by patients.

The Comparison of Procalcitonin Guidance Administer Antibiotics with Empiric Antibiotic Therapy in Critically Ill Patients Admitted in Intensive Care Unit

The empiric antibiotic therapy can result in antibiotic overuse, development of bacterial resistance and increasing costs in critically ill patients. The aim of the present study was to evaluate the effect of procalcitonin (PCT) guide treatment on antibiotic use and clinical outcomes of patients admitted to intensive care unit (ICU) with systemic inflammatory response syndrome (SIRS). A total of 60 patients were enrolled in this study and randomly divided into two groups, cases that underwent antibiotic treatment based on serum level of PCT as PCT group (n=30) and patients who undergoing antibiotic empiric therapy as control group (n=30). Our primary endpoint was the use of antibiotic treatment. Additional endpoints were changed in clinical status and early mortality. Antibiotics use was lower in PCT group compared to control group (P=0.03). Current data showed that difference in SOFA score from the first day to the second day after admitting patients in ICU did not significantly differ (P=0.88). Patients in PCT group had a significantly shorter median ICU stay, four days versus six days (P=0.01). However, hospital stay was not statistically significant different between two groups, 20 days versus 22 days (P=0.23). Early mortality was similar between two groups. PCT guidance administers antibiotics reduce antibiotics exposure and length of ICU stay, and we found no differences in clinical outcomes and early mortality rates between the two studied groups.

Postoperative sore throat after laryngoscopy with macintosh or glide scope video laryngoscope blade in normal airway patients

Background:

The Glide Scope videolaryngoscope provides a suitable view for intubation, with less force required.

Objectives:

The present study was conducted, to compare postoperative sore throat and hoarseness after laryngoscopy and intubation, by Macintosh blade or Glide Scope video laryngoscope in normal airway patients.

Patients and Methods:

Three hundred patients were randomly allocated into two groups of 150: Macintosh blade laryngoscope or Glide Scope video laryngoscope. The patients were evaluated for 48 hours for sore throat and hoarseness by an interview.

Results:

The incidence and severity of sore throat in the Glide Scope group, at 6, 24 and 48 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. In addition, the incidence of hoarseness in the Glide Scope group, at 6 and 24 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. The incidence and severity of sore throat in men, at 6 and 24 hours after the operation, were significantly lower than in the women.

Conclusions:

The incidence and severity of sore throat and hoarseness after tracheal intubation by Glide Scope were lower than in the Macintosh laryngoscope. The incidence and severity of sore throat were increased by intubation and longer operation times.

Thyromental height: a new clinical test for prediction of difficult laryngoscopy

BACKGROUND

The incidence of difficult laryngoscopy is reported in the range of 1.5% to 20%. We hypothesized that there is a close association between the occurrence of difficult laryngoscopy and the height between the anterior borders of the mentum and thyroid cartilage, while the patient lies supine with her/his mouth closed. We have termed this the "thyromental height test" (TMHT). Our aim in this study was to determine its utility in predicting difficult laryngoscopy.

METHODS

Three hundred fourteen consecutive male and female patients aged ≥ 16 years scheduled to undergo general anesthesia were invited to participate. Airway assessments were performed with the modified Mallampati test, thyromental distance and sternomental distance, and TMHT in the preoperative clinic. Afterward, Cormack and Lehane grade of laryngoscopy views was assessed during intubation. The laryngoscopist was unaware of airway assessments. As a primary end point, the validity and prediction indexes for the TMHT were calculated. Calculation of validity indexes for the 3 other methods of airway assessment was a secondary objective of this study.

RESULTS

The optimal sensitivity and specificity values were in the range of 47.46 to 51.02 mm. To facilitate clinical application, a cutoff value equal to 50 mm was chosen. TMHT was more accurate than the other tests (all P < 0.0001).

CONCLUSIONS

The TMHT appears to be a more accurate predictor of difficult laryngoscopy than the existing anatomical measurements.

Prophylactic administration of fibrinogen concentrate in perioperative period of total hip arthroplasty: a randomized clinical trial study

According to limitations in blood product resources and to prevent unnecessary transfusions and afterwards complications in perioperative period of total hip arthroplasty, authors administered fibrinogen concentrate in a pilot randomized clinical trial to evaluate bleeding and need to blood transfusion in preoperative period. Thirty patients (3-75 years old) with ASA physical status class I or II and candidate for total hip arthroplasty consequently enrolled in this study and randomly assigned into two groups: taking fibrinogen concentrate and control. Two groups were similar in serum concentration of fibrinogen, hemoglobin, and platelet preoperatively. After induction of general anesthesia 30 mg/kg fibrinogen concentrate was administered in the fibrinogen group. Blood loss, need to blood transfusion and probable complications were compared between two groups. The mean operation time was 3.3 ± 0.8 hours in the fibrinogen group and 2.8 ± 0.6 hours in the placebo group, and this difference was statistically significant (P=0.04). There was a significant correlation between operation time and blood loss during surgery (P=0.002). The mean transfused blood products in the fibrinogen and control group was 0.8 ± 1.01 units and 1.06 ± 1.2 units respectively (P=0.53). The mean of perioperative blood loss was 976 ± 553 ml in the fibrinogen group and 1100 ± 350 ml in the control group, but this difference was not significant between two groups. By adjusting time factor for two groups, we identified that the patients in fibrinogen group had lower perioperative bleeding after adjusting time factor for two groups (P=0.046). None of the patients had complications related to fibrinogen concentrate administration. The prophylactic administration of fibrinogen concentrate was safe and effective in reducing bleeding in the perioperative period of total hip arthroplasty.

Inadvertent intrathecal injection of large dose magnesium sulfate

The case is a 35-year-old man who underwent spinal anesthesia for emergency strangulated inguinal hernia repair. About five minutes after 3 ml intrathecal drug injection, the patient suffered respiratory distress, bradycardia, hypotension and loss of consciousness. The patient was rapidly intubated and crystalloid infusion and epinephrine drip were established. Thereafter, he was admitted in intensive care unit. Search for the cause revealed us that 3 ml of magnesium sulfate (50%) was injected mistakenly for spinal anesthesia. Two days later, he was extubated and on the fifth day, he was discharged from the hospital without an obvious evidence of complication.

Magnesium Can Decrease Postoperative Physiological Ileus and Postoperative Pain in Major non Laparoscopic Gastrointestinal Surgeries: A Randomized Controlled Trial

BACKGROUND

Magnesium is an antagonist of (N-methyl D-Aspartate) NMDA receptor and its related canals, and may affect perceived pain.

OBJECTIVES

The aim of this study was to evaluate the impact of intravenous magnesium on the hemodynamic parameters, analgesic consumption and ileus.

PATIENTS AND METHODS

A randomized, double blind, placebo controlled study was performed. Thirty two patients of ASA I or II, scheduled for major gastrointestinal (GI) surgery, were divided into magnesium and control groups. Magnesium group received a bolus of 40 mg/kg of magnesium sulphate, followed by a continuous perfusion of 10 mg/kg/h for the intraoperative hours. Postoperative analgesia was ensured by Morphine patient-controlled analgesia (PCA). The patients were evaluated by Intraoperative hemodynamic parameters, the postoperative pain by numeral rating scale (NRS), and the total dose of intraoperative and postoperative analgesic consumption. Postoperative hemodynamic, respiratory parameters, physiological gastrointestinal obstruction (ileus), and side effects were also recorded.

RESULTS

The study included 14 males and 18 females. Age range of patients was 17 to 55 years old. The average age in the magnesium group was 41.33 ± 10.06 years and45.13 ± 11.74 years in control group. Mean arterial pressure (MAP) of magnesium group decreased during the operation but increased in control group (P < 0.001), and systemic vascular resistance (SVR) of magnesium group decreased during the operation also (P < 0.02) but increased in control group. Postoperative cumulative Morphine consumption in magnesium group, was significantly in lower level (P = 0.026). For NRS, severe pain was significantly lower, in magnesium group, at all intervals of postoperative evaluations, but moderate and mild pain were not lower significantly. Duration of postoperative ileus was 2.3 ± 0.5 days in magnesium group, and 4.2 ± 0.6 days in control group (P = 0.01).

CONCLUSIONS

Intravenous magnesium reduces postoperative ileus, postoperative severe pain and intra/post operative analgesic requirements in patients after major GI surgery. No side effects of magnesium in these doses were seen, so it seems to be beneficial along with routine general anesthesia in major GI surgeries.

Trigeminocardiac reflex in neurosurgical practice: An observational prospective study

BACKGROUND

Considering wide variations regarding the incidence of trigeminocardiac reflex (TCR) during cranial neurosurgical procedures, and paucity of reliable data, we intended to design a prospective study to determine the incidence of TCR in patients undergoing standard general anesthesia for surgery of supra/infra-tentorial cranial and skull base lesions.

METHODS

A total of 190 consecutive patients candidate for elective surgery of supra-tentorial, infra-tentorial, and skull base lesions were enrolled. All the patients were operated in the neurosurgical operating room of a university-affiliated teaching hospital. All surgeries were performed using sufficient depth of anesthesia achieved by titration of propofol-alfentanil mixture, adjusted according to target Cerebral State Index (CSI) values (40-60). All episodes of bradycardia and hypotension indicating the occurrence of TCR during the surgery (sudden decrease of more than 20% from the previous level) were recorded.

RESULTS

Four patients, two female and two male, developed episodes of TCR during surgery (4/190; 2.1%). Three patients showed one episode of TCR just at the end of operation when the skin sutures were applied while CSI values were 70-77 and in the last case, when small tumor samples were taken from just beneath the lateral wall of the cavernous sinus TCR episode was seen while the CSI value was 51.

CONCLUSION

TCR is a rare phenomenon during brain surgeries when patient is anesthetized using standard techniques. Keeping the adequate depth of anesthesia using CSI monitoring method may be an advisable strategy during whole period of a neurosurgical procedure.

General anesthesia versus combined epidural/general anesthesia for elective lumbar spine disc surgery: A randomized clinical trial comparing the impact of the two methods upon the outcome variables

Background:

General anesthesia (GA) is the most frequently used technique for lumbar spine disc surgery. The aim of this study was to compare the intraoperative variables and postoperative outcome after GA and combined general/epidural anesthesia (CEG) in patients undergoing elective lumbar spine disk surgery.

Methods:

Eighty patients who underwent one or two level of laminectomy/discectomy during a 2 year period were enrolled in this randomized controlled trial (RCT). They were randomly selected to undergo GA or CEG. The data recorded during surgery were: The patients’ heart rate (HR), mean arterial blood pressure (MABP), amount of blood loss, and the medication used during anesthesia. The severity of pain score, total analgesic consumption, and complications were recorded in the postoperative period.

Results:

The MABP, HR, blood loss, and anesthetic medication were significantly lower in CEG group in comparison with that of GA group. In the postoperative period, the pain score and total analgesic requirement was lower in the CEG group and less complication were encountered in this group.

Conclusion:

The results of this study revealed that CEG have some advantages over GA in reducing the blood loss and anesthetic medication during the operation and it is also more effective in control of pain with fewer complications during the postoperative period.

The effect of needle type, duration of surgery and position of the patient on the risk of transient neurologic symptoms

Background

The incidence of transient neurologic symptoms (TNS) after spinal anesthesia with lidocaine is reported as high as 40%.

Objectives

This prospective clinical trial was designed to determine the incidence of TNS in patients who underwent spinal anesthesia with two different needles, in two different surgical positions.

Patients and Methods

The present randomized clinical trial was conducted on 250 patients (ASA I-II), who were candidates for surgery in supine or lithotomy positions. According to the needle type (Sprotte or Quincke) and local anesthetics (lidocaine and bupivacaine) all patients were randomly divided into four groups. After performing spinal anesthesia in sitting position, the position was changed into supine or lithotomy, according to surgical procedure. The patients were observed for complications of spinal anesthesia during the first five post-operative days. The primary end-point for this trial was to recognize the incidence of TNS among the four groups. Our secondary objective was to evaluate the effect of patient's position, needle type, and duration of surgery on the development of TNS following spinal anesthesia.

Results

TNS was most commonly observed when lidocaine was used as anesthetic drug (P = 0.003). The impact of needle type, was not significant (P = 0.7). According to multivariate analysis, the duration of surgery was significantly lower in cases suffering from TNS (P = 0.04). Also, the risk of TNS increased following surgeries performed in lithotomy position (P = 0.00).

Conclusions

According to the results of this clinical study, spinal anesthesia with lidocaine, and the lithotomy position in surgery increased the risk of TNS.

Impact of subcutaneous infiltration of 0.5% bupivacaine on post-operative C-reactive protein serum titer after craniotomy surgery

BACKGROUND

Tissue injuries may provoke neuro-hormonal response which in turn may lead to release of inflammatory cytokines. We hypothesize that block of afferent sensory pathways by infiltration of 0.5% bupivacaine in the scalp may decrease neuro-hormonal response in the neurosurgical patient.

METHODS

After obtaining informed consent, forty ASA physical statuses I, II, or III patients between the ages of 18 and 65 years were enrolled randomly into two equal groups to receive either 20 ml of 0.5% bupivacaine (group A) or 20 ml of 0.9% normal saline as a placebo (group B) in the site of pin insertion and scalp incision. As the primary outcome we checked serum C-reactive protein (CRP) levels before implementation of noxious stimulus, 24h, and 48h after the end of surgery to compare these values between groups. In addition, mean arterial pressure (MAP) and heart rate (HR) were checked at baseline (after the induction of anesthesia), one minute after pin fixation and 5, 10, and 15 minute after skin incision and the recorded values were compared between groups.

RESULTS

No significant difference was found between serum CRP levels of the two groups. Comparison of mean HR between groups shows no significant difference. The mean of MAP was significantly lower in the group A in comparison with the group B (p< 0.001).

CONCLUSION

The results of this study confirm that 0.5% bupivacaine scalp infiltration before skull-pin holder fixation and skin incision could not decrease post-operative C-reactive protein level.

ICU sedation with haloperidol-propofol infusion versus midazolam-propofol infusion after coronary artery bypass graft surgery: a prospective, double-blind randomized study

Combinations of hypnotics with or without opiates are commonly used in agitated patients. We hypothesized that combination of haloperidol-propofol in comparison with midazolam-propofol would lower consumption of propofol and lead to better hemodynamic and respiratory profile during sedation of agitated patients. Among 108 patients admitted in our ICU, 60 patients were agitated according to Ramsay Sedation Score (RSS) and randomly divided into two groups. Morphine sulfate (0.05 mg/kg) was administered to all patients for relief of postoperative pain. In one group, sedative infusion was started with 1 mg/h of haloperidol plus 25 μg/kg/min of propofol after bolus injection of 2 mg haloperidol. In the other group, midazolam1 mg/h and propofol 25 μg/kg/min were infused after a bolus injection of 2 mg midazolam. Propofol infusion was adjusted to keep bi-spectral index between 61-80 and the RSS between 3-5. Hourly propofol consumption was recorded during 24 h of sedation and compared statistically. We also compared SpO 2 , arterial blood gas variables, hemodynamic parameters and episodes of respiratory depression (SpO 2 ≤85%) requiring respiratory support between the groups. Haloperidol, when added to propofol infusion, decreased its consumption at all the measured times (P = 0.001). There was no significant difference in hemodynamic variables between two groups, but the episodes of respiratory depression was significantly higher in propofol-midazolam group (P = 0.02). We conclude that haloperidol-propofol infusion decreases propofol requirements in the agitated patients. Besides, this combination showed a better profile in terms of occurrence of respiratory depression.

Postoperative gabapentin to prevent postoperative pain: a randomized clinical trial

BACKGROUND

Gabapentin is an anticonvulsant that has postoperative analgesic effects but there are limited studies on its postoperative administration.

OBJECTIVES

The present study was conducted to evaluate the effect of the postoperative oral gabapentin on pain and morphine consumption.

PATIENTS AND METHODS

In a double blind, randomized study, 64 patients undergoing internal fixation of tibia under spinal anesthesia were randomly assigned to receive oral gabapentin or placebo immediately after the surgery. Pain scores were recorded at time points of 2, 12 and 24 hours postoperatively using visual analog scale (VAS). Time duration from the end of surgery until morphine administration and total morphine requirement in the first 24 hours were recorded.

RESULTS

The estimated duration of surgeries was 120-150 minutes. VAS score was not significantly different between the two groups at 2, 12 and 24 hours after surgery. There was no significant morphine consumption difference between the groups.

CONCLUSIONS

Our study showed no significant analgesic efficacy of oral gabapentin 300 mg immediately after tibia internal fixation surgery under spinal anesthesia at time points of 2, 12 and 24 hours postoperatively.

Effects of tight versus non tight control of metabolic acidosis on early renal function after kidney transplantation

Background

Recently, several studies have been conducted to determine the optimal strategy for intra-operative fluid replacement therapy in renal transplantation surgery. Since infusion of sodium bicarbonate as a buffer seems to be safer than other buffer compounds (lactate, gluconate, acetate)that indirectly convert into it within the liver, We hypothesized tight control of metabolic acidosis by infusion of sodium bicarbonate may improve early post-operative renal function in renal transplant recipients.

Methods

120 patients were randomly divided into two equal groups. In group A, bicarbonate was infused intra-operatively according to Base Excess (BE) measurements to achieve the normal values of BE (−5 to +5 mEq/L). In group B, infusion of bicarbonate was allowed only in case of severe metabolic acidosis (BE ≤ −15 mEq/L or bicarbonate ≤ 10 mEq/L or PH ≤ 7.15). Minute ventilation was adjusted to keep PaCO₂ within the normal range. Primary end-point was sampling of serum creatinine level in first, second, third and seventh post-operative days for statistical comparison between groups. Secondary objectives were comparison of cumulative urine volumes in the first 24 h of post-operative period and serum BUN levels which were obtained in first, second, third and seventh post-operative days.

Results

In group A, all of consecutive serum creatinine levels were significantly lower in comparison with group B. With regard to secondary outcomes, no significant difference between groups was observed.

Conclusion

Intra-operative tight control of metabolic acidosis by infusion of Sodium Bicarbonate in renal transplant recipients may improve early post-operative renal function.

Continuous sedation-analgesia delays diagnosis of compartment syndrome in a patient with intra-aortic balloon pump

Compartment syndrome is a rare, devastating complication of coronary artery bypass grafting (CABG) and intra-aortic balloon pump (IABP). Prompt diagnosis is based on symptoms and signs and is paramount for limb rescue. This report describes a CABG patient with IABP in whom receiving continuous analgesia-sedation obscured the symptoms of compartment syndrome.

Attitudes of anesthesiology residents and faculty members towards pain management

INTRODUCTION

There is a large armamentarium of pain-reducing interventions and analgesic choices available to anesthesiologists, but oligoanalgesia continues to be a large problem. We studied the attitudes of residents and faculty members of anesthesiology towards different domains of pain medicine.

METHODS

anonymous questionnaires were mailed to 68 professionals containing demographic and personal data plus 40 items in 10 domains: control, emotion, disability, solicitude, cure, opioids, harm, practice settings, training, and barriers. Internal consistency was 0.70 and the test-retest reliability was 0.80.

RESULTS

With 81% response rate, we observed desirable beliefs towards all domains except moderately undesirable beliefs towards the domain solicitude. Scores of residents and faculties were not significantly different.

CONCLUSION

Continuing education programs on both the international guidelines, routine professional education, are needed to improve attitudes towards pain control.

Comparison of metformin and insulin in the control of hyperglycaemia in non-diabetic critically ill patients

INTRODUCTION

It is accepted that preventing hyperglycaemia during critical illness while assuring adequate caloric intake can reduce mortality and morbidity. The aim of this study was to compare the metabolic effects of metformin and insulin on hyperglycaemia in ICU patients.

METHODS

This double-blind randomised clinical trial was performed on 24 patients who were admitted to the intensive care unit (ICU) from 20 March to 20 September 2007. All patients with serious injuries or with major non-abdominal surgeries were included if they met the inclusion criteria, and were assigned randomly to one of the study groups. Patients in Group 1 received intensive insulin therapy, and patients in Group 2 were treated with metformin. Moreover, the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system was used to grade disease severity.

RESULTS

Both glycaemic management protocols led to significantly improved glucose levels without any report of hypoglycaemia. The mean initial glucose levels for the insulin group decreased significantly after the intravenous infusion of insulin (p < 0.001). Additionally, the blood glucose concentration was significantly lower after two weeks of metformin administration compared to baseline measurements (p < 0.001). Moreover, the blood glucose concentration decrease during these two weeks was significantly higher in the insulin group (p = 0.01). Besides, APACHE II score was lower than baseline at the end of the study for both therapeutic groups (score of 10 vs. 15 [insulin] and 16 [metformin]). Finally, new renal dysfunction (maximum serum creatinine level at least double the initial value) was observed in three of the patients (two patients from the metformin group and one from the insulin group) in the last days of the protocol, although none of the patients showed lactic acidosis after ICU admission.

CONCLUSIONS

Both metformin and intensive insulin therapy significantly decreased hyperglycaemia in ICU patients. Insulin caused a greater reduction in blood glucose concentration but required more attention and trained personnel.

Intraurethral instillation of ketamine for male rigid cystoscopy

PURPOSE

This study was conducted to examine the efficacy of ketamine along with lidocaine gel for instillation in the male urethra for easiness of outpatient rigid cystoscopy, as compared with only using lidocaine gel.

PATIENTS AND METHODS

A total of 60 consecutive men who were scheduled to undergo rigid cystoscopy were randomly assigned to receive either 10 mL of 2% lidocaine gel combined with 2 mL normal saline, or 10 mL of 2% lidocaine gel combined with 2 mL ketamine (100 mg). Hemodynamic changes and the level of pain perception of patients at the beginning, during, and after every procedure in both groups were recorded by using the visual analogue scale.

RESULTS

There were no significant differences in hemodynamic changes between the two groups; however, the perception of pain was significantly decreased when lidocaine was used in conjunction with ketamine, most notably during the first 5 minutes of cystoscopy.

CONCLUSIONS

Instillation of lidocaine gel in conjunction with ketamine in the urethra could decrease pain perception and make men undergoing outpatient rigid cystoscopy more comfortable during the procedure.

Sanosil, a more effective agent for preventing the hospital-acquired ventilator associated pneumonia

PURPOSE

The aim of this study is to compare the effects of Sanosil and glutaraldehyde 2 percent in disinfecting ventilator connecting tubes in an intensive care unit (ICU) environment.

DESIGN/METHODOLOGY/APPROACH

The 12-week open-labelled clinical trial was conducted in the surgical ICU of a teaching hospital from March to May 2005. In the first phase of the study, high level disinfection was performed using glutaraldehyde 2 percent, whereas Sanosil was used as the disinfectant agent of the second phase. Samples for microbial culture were obtained from the Y piece, the expiratory limb proximal to the ventilator and the humidifier in different stages; the results were then compared.

FINDINGS

Positive culture was more frequently reported in Y pieces, humidifiers and expiratory end of ventilators. Comparing the two groups, there were more positive cultures in the glutaraldehyde group (p value = 0.005); multiple organism growths, gram negative, gram positive and fungi were also more frequent in this group (p value = 0.01; 0. 007; 0. 062; 0.144, respectively).

ORIGINALITY/VALUE

The paper shows that Sanosil is an effective agent in reducing the contamination risk in the tubes used in ICUs.

The risk factors and the treatment course of cerebral venous thrombosis: an experience of 41 cases

BACKGROUND

The present study was designed to describe the characteristics, risk factors and prognosis of patients diagnosed with CVT in our center.

METHOD

The present retrospective cross-sectional study was conducted on patients diagnosed with cerebral vein or sinus thrombosis based on the patients' clinical presentation and the findings of the imaging studies between 2003 and 2008. The patients were studied for possible risk factors and the resultant outcome after terminating the therapeutic course.

RESULTS

Headache, the most common symptom reported in 80% of the cases, was considered the first symptom in only 46% of these patients. Coma, focal motor deficit at presentation, hemorrhagic conversion of infarction and thrombosis in more than one sinus were factors associated with unfavorable outcome in these patients.

CONCLUSION

Physicians should always have CVT in mind while examining patients particularly women on pills who complain about headache. More studies however are needed to point out more specific presentations which would lead to the early diagnosis of CVT in the patients.

The GlideScope facilitates nasogastric tube insertion: a randomized clinical trial

BACKGROUND

The GlideScope (Saturn Biomedical Systems, B.C., Canada) is a reusable videolaryngoscope and is considered an effective device for tracheal intubation. We designed this study to evaluate the application of this device in nasogastric tube (NGT) insertion.

METHODS

This randomized clinical trial was performed at a teaching hospital on 80 adult patients who required intraoperative placement of an NGT. The patients were divided into 2 groups (the control and the GlideScope group) using computerized, random allocation software. In the control group, the NGT was inserted blindly as commonly performed in operating rooms; however, in the GlideScope group, the tube was inserted with the assistance of a GlideScope. The number of attempts for NGT insertion and the time required for inserting the NGT properly along with the occurrence of possible complications were recorded.

RESULTS

The mean intubation time in the GlideScope group was 27.7 +/- 20.7 s shorter than that in the control group. NGT insertion in the first attempt was successful in approximately 85% of the patients in the GlideScope group; in the control group, however, the tubes were inserted successfully after the first attempt in 57.5% of the patients. Complications were reported in 14 patients (35%) of the control group and 8 patients (20%) of the GlideScope group.

CONCLUSION

GlideScope facilitates NGT insertion and reduces the duration of the procedure.

Loss of consciousness secondary to lead poisoning--case reports

Diagnosis of lead toxicity could be difficult in IC setting because of overlap of signs and symptoms with other diseases. This is a report of two Iranian patients (father and son) with severe level of whole blood lead concentration, developing into unconsciousness.

A prospective randomized trial comparing the technique of spinal and general anesthesia for lumbar disk surgery: a study of 100 cases

BACKGROUND

General anesthesia and regional anesthesia have both been shown to be suitable techniques for patients undergoing lower thoracic and lumbar spine surgery; however, GA is the most frequently used method. The purpose of this study was to conduct an acceptable RCT to compare the intraoperative parameters and postoperative outcome after SA and GA in patients undergoing elective lumbar disk surgery.

METHODS

Patients undergoing laminectomy for herniated lumbar disk during the years 2005 and 2007 were enrolled. They were randomly selected to undergo GA and SA. The variables recorded during the operation were the patients' HR, MAP, amount of blood loss, and surgeons' satisfaction with the operating conditions. The severity of pain, nausea, vomiting, and length of stay in the hospital were recorded in the postoperative course.

RESULTS

The mean blood loss was less in the group undergoing GA; however, the difference was not statistically significant. The surgeon's satisfaction was reported to be higher in the GA group. No major intraoperative complication was reported in either series. During the recovery period, hypertension was reported to happen more frequently in the patients undergoing GA; and postoperative nausea and vomiting were more frequent among patients recovering from SA.

CONCLUSION

Contrary to previous studies, the findings of the present study revealed that SA has no advantages over GA. Moreover, it was showed that GA can reduce the related risks and complications in several aspects.

Subcutaneous Tramadol Infiltration at the Wound Site Versus Intravenous Administration after Pyelolithotomy

Background:

Recently, the peripheral anesthetic effect of tramadol has been the theme of many studies. The postoperative analgesic effects of subcutaneous wound infiltration with tramadol have not been extensively studied and compared with those of intravenous administration.

Objective:

To compare the therapeutic effects and complications of intravenous versus local wound infiltration of using tramadol following pyelolithotomy.

Methods:

This double-blind study was carried out on 60 patients (age 18–60 y) of American Society of Anesthesiologists physical status I–II who were awaiting pyelolithotomy in Sina Hospital, Tehran, Iran, during 2006 and 2007. They were randomly assigned to receive intravenous or subcutaneous wound infiltration with tramadol. Vital signs, the intensity of pain (visual analog scale), and the level of consciousness (Ramsey Sedation Scale [RSS]), as well as the frequency of nausea and vomiting were recorded during 30 minutes to 1 hour after the patient entered the recovery room. Vital signs were also recorded every hour until 6 hours postoperatively and then on the day after the patient was transferred to the ward.

Results:

The RSS was lower in patients who had received subcutaneous infiltration of tramadol (p < 0.001). A significant difference was noted in the severity of pain between the groups; it was higher in the group that received intravenous tramadol. The average time for the first meperidine requirement was 45.2 ±8.4 min (mean ± SD) in the subcutaneous group and 21.6 ± 12.4 min in the intravenous group. Total meperidine consumption was lower in patients who had received subcutaneous wound infiltration with tramadol compared with those who had received intravenous tramadol (p < 0.001). Nausea and vomiting were more frequent during the first hour of recovery; the complication, however, was less frequent in the subcutaneous group.

Conclusions:

Subcutaneous wound infiltration with tramadol reduces postoperative opioid consumption and produces less nausea and vomiting than does intravenous administration.

Teaching critical appraisal and statistics in anesthesia journal club

BACKGROUND

This study was designed to assess the effectiveness of a series of journal clubs held for anesthesiology residents in promoting their awareness of research methods and statistical analysis, as well as their skills in critical thinking and appraisal.

MATERIAL AND METHODS

Twenty-four journal club sessions were held between September 2006 and August 2007 for 16 residents of anesthesiology. A 31 multiple-choice question (MCQ) was taken as pretest and posttest to evaluate the participants' level of awareness in research methodology and statistical analysis. Their competence in critical thinking and appraisal was also evaluated by evaluating a randomized controlled trial paper using the CONSORT checklist before and after the course.

RESULTS

Residents' awareness in the application of information improved (P = 0.012), as well as research methodology (combined study design and application of information, P = 0.017). Their ability in critical appraisal did also significantly rise at the end of the course (P < 0.001).

CONCLUSION

Journal clubs can enable residents to develop the knowledge, expertise and enthusiasm needed to undertake research plans and can also enhance their ability in critical thinking and scientific reading.

Effects of normal saline vs. lactated ringer's during renal transplantation

AIM

We hypothesized that normal saline (NS) may have more deleterious effects compared with lactated ringer (LR) in kidney transplant recipients because of the higher risk of acidosis and higher levels of serum potassium. Thus, the aim of this study was to determine the safety of LR if used during a renal transplant.

METHODS

Adults undergoing kidney transplantations were enrolled in a double-blinded randomized prospective clinical trial. They were divided into two groups in order to receive NS and LR infusion as intraoperative IV fluid replacement therapy.

RESULTS

There was a significant difference in the serum potassium level (p = .000) and the PH (p = .007) between the two groups at the end of transplantations. Two patients in the LR group lost their kidneys due to vascular graft thrombosis. In other words, hyperkalemia and acidosis occurred more frequently in the NS group while thrombotic events may be of concern in the LR group.

CONCLUSION

Compared with NS, LR infusion may lead to a lower serum potassium level and a lower risk of acidosis, while there is major concern of the hypercoagulable state in these patients.