[Spinal anesthesia in renal transplantation]

Renal transplantation is the preferred therapeutic method for patients with end-stage renal disease. Patients with renal failure have significant associated medical conditions, such as cardiovascular disease. The suitable anesthesia for renal transplantation requires minimal toxicity for the transplanted organ, as well as sufficient pain relief and maintenance of optimal blood pressure and intravascular volume to keep renal functions. The aim of this study was to improve our experience of spinal anesthesia in patients undergoing renal transplantation. Sixty consecutive patients scheduled for elective renal transplantation over a period of two years who consented for spinal anesthesia were enrolled in the study. Intraoperative hemodynamic, intravenous fluids and infused blood products, duration of surgery, urine output and arterial blood gas and intensity of pain score in the recovery room were monitored. We also noted intraoperative and postoperative complications. Spinal anesthesia was satisfactory in all, but in five patients they required supplementation with general anesthesia for excessively prolonged surgery. There were no significant intraoperative hemodynamic changes. The total intravenous fluid used during surgery was 65.15 +/- 7.2 mL/kg, the mean surgical time was 170 +/- 22 min. The mean of mean arterial pressure [MAP] during the operation was 98 +/- 12 mm hg. There was no significant acidosis at the end of the operation [PH=38 +/- 0.03]. Also the mean intensity of pain was 4 +/- 2 in recovery and a few of patients suffered from bladder catheter bladder discomfort in the recovery room [8 patients]. Spinal anesthesia is a successful regional anesthetic technique in well selected patients for renal transplantation. A successful outcome in this technique is dependent on close intra-operative monitoring, optimization of intravascular fluid volume and keep the hemodynamic status in optimal range.

[Trigemino-cardiac reflex during skull-base neurosurgeries: a case report]

The Trigemino-cardiac reflex [TCR] has been studied as a phenomenon including; bradycardia, arterial hypotension, apnea and gastric hypermotility during manipulation of the peripheral or central parts of the trigeminal nerve. We report a case of a 26-year-old man undergoing surgery for a skull base extra axial tumor in right petrous bone suspected to metastasis of a previous renal cell carcinoma which had been treated four years ago. The patient presented with continuous and unilateral headache and difficulty in swallowing, sensory neural hearing loss, nasal speech and tongue deviation to left side. He underwent general anesthesia with standard monitoring and total intravenous anesthetic technique. The first episode of sudden onset bradycardia and hypotension related to surgical manipulation was detected intraoperatively in which the heart rate spontaneously returned to normal level once the surgical manipulation stopped. However, it repeated several times by beginning of tumor resection and manipulation in the region of trigeminal nerve. The intensity of bradycardia in subsequent episodes of TCR was relatively crescendo and had no fatigability. Finally, it was treated by administration of a single dose of atropine [0.5mg/IV] and did not happen again. The risk of TCR should be considered in any neurosurgical intervention involving trigeminal nerve and its branches, especially at the skull base surgeries. The vigilance of the medical team and continuous intraoperative hemodynamic monitoring alerts the surgeons to interrupt surgical maneuvers upon the TCR occurrence, immediately.

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

[Evaluation of patient satisfaction with anesthesia care]

The assessment of patient satisfaction with anesthesia, the balance between expectations and perception of what was received, is an essential component of continuous quality improvement in anesthesiology. In our center there have been few studies conducted in the anesthesia field, which have assessed patient's satisfaction. In this prospective study we have evaluated patient satisfaction with anesthesia in patients 24 h after surgery. This study was performed in Sina hospital in Tehran, Iran on patients aged more than 18 yr. They all underwent elective surgical procedures with anesthesia. One of the anesthesia staff members took the interview one day after surgery and asked the patients questions for the structured questionnaire designed to measure patient satisfaction with anesthesia. At the same time, some specific questions were also asked to find factors that could be associated with such satisfaction. The data was gathered from 500 patients [mean age: 41 +/- 16 yr; and males: 65.2%]. The overall satisfaction [complete and relative] was high [98.8%]; although 6 patients [1.2%] were dissatisfied with their anesthesia care. After analysis of several factors related to the patients' surgery and anesthesia, a strong relation was found between spinal anesthesia and satisfaction [p=0.003].There was not any relation between age, gender, education, duration of anesthesia and kind of surgery with patients' satisfaction. Our study found that patient satisfaction with anesthesia was very high in our center and the only factor that increased patient's satisfaction was spinal anesthesia

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

Tissue injuries may provoke neuro-hormonal response which in tum 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. After obtaining informed consent, forty ASA physical statuses I, II, or III patients between the ages of 18 and 65 years were emolled 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 [RR] 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. 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]. 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

[Evaluation of oral clonidine effects on prevention of post-anesthesia shivering]

Shivering is a common post anesthesia complication. Intravenous Clonidine administration at induction of anesthesia is a useful drug for decreasing of incidence and severity of post-anesthesia shivering. As Clonidine injection can induce side effects therefore we evaluated the oral Clonidine premedication on post-anesthesia shivering. In a RCT, 60 adult patients in ASA class 1 and 2 scheduled for cholecystectomy were assigned to 2 groups. 2 hours before anesthesia, 0.2 mg oral Clonidine was administrated and to the other group placebo was administered. Surgery room temperature was adjusted for 21-23[degree][c]. At the end of the anesthesia, the patients' shivering was evaluated in the recovery room by "Crossley andMahajan shivering score". There was no difference at decrease of SpO2 and H.R. and MAP between 2 groups. There was no difference in average time of emergence between 2 groups. Overall 75% of the patients shivered after anesthesia. Median shivering score in clonidine group was 1.97 and in placebo were 2.87. It became revealed that there was clear difference at shivering score between 2 groups [less severe or generalized shivering patients in test group]. 0.2 mg Clonidine tablet, 2 hours before anesthesia is similar to injecting drug and is effective in prevention of post-anesthesia shivering but its complication is less. Lack of difference at hemodynamics and SpO2 and emergence in our study may be due to slow absorption of oral Clonidine

Post dural puncture headache after cesarean section, a teaching hospital experience

This prospective study examined the frequency of Post-Dural Puncture Headache [PDPH] in 361 parturient women undergoing spinal anesthesia for cesarean section in a teaching hospital of Tehran University of Medical Sciences. Spinal anesthesia was performed using 25 gauge Quincke needles in all women. Patients were followed up to determine incidence of PDPH and then tried to compare those with or without PDPH using statistical methods to determine risk factors of PDPH. The overall incidence of PDPH was 10.8 percent in this study. In terms of probable risk factors which were compared between the two groups of patients, no statistically significant differences were found. The incidence of PDPH in our study was higher than studies which used pencil - tipped needles and we determined that the occurrence of PDPH is not associated to some factors like the previous history of nonspecific headache, Body Mass Index, age, type of local anesthetic, previous history of PDPH, experience of operator, history of habitual tea and coffee drinking

[ incidence of transient neurologic syndrome after spinal anesthesia with lidocaine or bupivacaine: the effects of needle type and surgical position: brief report]

Burning Transient Neurologic Syndrome [TNS] which was first described by Schneider et al in 1993, is defined as a transient pain and dysesthesia in waist, buttocks and the lower limbs after spinal anesthesia. 1, 2 The incidence of TNS after spinal anesthesia with lidocaine is reported to be as high as 10-40%.3,4 This prospective study was designed to determine the incidence of TNS with two different types of drugs, lidocaine and bupivacaine, in lithotomy or supine positions as the primary outcomes and to determine the association between two different types of needles and surgical positions with the occurrence of TNS as the secondary outcome. The present study was conducted on 250 patients [ASA I-II], aged 18-60 years old, who were candidates for surgery in supine or lithotomy positions. According to the needle type [Sprotte or Quincke] and the local anesthetic [lidocaine or bupivacaine] all patients were randomly divided into four groups. After establishing standard monitoring, spinal anesthesia was performed in all sitting patients by attending anesthesiologists at L2-L3 or L3-L4 levels. The patients were placed in supine or lithotomy position, in regards to the surgical procedure. During the first three postoperative days, patients were observed for post spinal anesthesia complications, especially TNS. Any sensation of pain, dysesthesia, paresthesia or hyperalgesia in the low back area, buttocks, the anterior or posterior thigh, knees, either foot or both feet were recorded. Moreover, duration of pain, its radiation and its relation to sleep and the patients' position were all carefully considered. Ultimately, the patients' response to opioid [pethidine] for analgesia was determined. The incidence of TNS was higher when spinal anesthesia was induced with lidocaine [68% vs. 22%, P=0.003]. TNS developed in 85% of the patients in lidocaine group and 58% in bupivacaine group after surgery in lithotomy position [P=0.002]. In 77 patients pain was in lumbosacral area that radiated to lower limbs and was aggravated in sitting position but in 22 patients pain was in thighs with no radiation. The mean visual analogue scale [VAS] for the determination of pain severity was six in all patients. Pain was alleviated by the administration of pethidine. With regard to the needle type, there were no significant differences between the two types of needles [P=0.7]. According to the results of this prospective study, it seems that induction of spinal anesthesia by lidocaine combined with surgical lithotomy position increases the risk of TNS. Our study is in concordance with Keld's study.5 Higher neurotoxicity of lidocaine in comparison with bopivacaine may justify the higher incidence of TNS in the lidocaine group. Moreover, natural lumbar lordosis is maintained better in supine position while it is lost in lithothomy position which may lay traction forces on cauda equina or other nerve roots in the lumbar area leading to neuropraxia