Comparative Study of the Prophylactic Effects of Intravenous Injection of Dexmedetomidine, Ondansetron, and Pethidine on Postoperative Shivering of Abdominal Surgery under General Anesthesia: A Randomized Clinical Trial.

BACKGROUND: postoperative shivering is a common complication of various surgical, so far no acceptable theory has been presented on the prevention of it. The aim of this study was to compare the effect of intravenous injection of dexmedetomidine, ondansetron, and pethidine on postoperative shivering among patients under abdominal surgery. MATERIALS AND METHODS: In a double-blind clinical trial study, 128 patients undergoing abdominal surgery were selected and randomly divided into four groups of 32. In the 4 groups, 0.5 µg/kg dexmedetomidine, 0.5 mg/kg pethidine, 0.1 mg/kg ondansetron, and the same volume of normal saline were injected intravenously when anesthetics were discontinued and the incidence and severity of postoperative shivering were determined and compared in four groups. RESULTS: The incidence of postoperative shivering was 12.5% in the dexmedetomidine group, 31.3% in the ondansetron group, 31.3% in the pethidine group, and 50% in the control group (P = 0.015). The mean of shivering severity in the four groups was 1.33 ± 0.5, 0.17 ± 0.8, 1.09 ± 0.4, and 1.13 ± 0.39, and the difference between the four groups was significant (P = 0.005). CONCLUSION: The use of all three drugs of dexmedetomidine, ondansetron, and pethidine is effective in decreasing the incidence of postoperative shivering, but the use of dexmedetomidine is associated with less postoperative shivering, better hemodynamic stability, and fewer other postoperative complications.

Evaluation of Warming Effectiveness on Physiological Indices of Patients Undergoing Laparoscopic Cholecystectomy Surgery: A Randomized Controlled Clinical Trial.

PURPOSE: The present study aimed to evaluate the impact of warming on physiological indices of patients undergoing laparoscopic cholecystectomy. DESIGN: The study was a three-group randomized controlled clinical trial. METHODS: In the present study, 96 patients were assigned to three groups: forced-air warming system group; warmed intravenous fluid group; and control group. The intervention was performed immediately after the anesthesia induction. Physiological indices (core body temperature, blood pressure, and heart rate) were evaluated at 15-minute intervals, and postoperative shivering was also recorded. FINDINGS: The mean systolic blood pressure and the mean heart rate were significantly different in each warming group before, during, and after surgery, but the three groups had no significant differences in terms of physiological indices at any time (P > .05). Postoperative shivering was not seen in any group. CONCLUSIONS: Both interventions had similar effects on physiological indices. Therefore, the recommendation is to use the warming method according to patient's other conditions.

Bispectral Index in Poisoning Cases with Multi-drug Ingestion: A Predictable Role for Early Endotracheal Intubation.

OBJECTIVE: Bispectral index (BIS) is one of the several methods used to monitor the depth of anesthesia. Poisoning with ingestion of different drugs is one of the most common poisonings that have different clinical signs from drowsiness to coma. This study was performed to compare the BIS index number in poisoned patients with multi drugs ingestion with or without the need for endotracheal intubation. METHODS: This cross-sectional study was performed on poisoned patients with ingestion of different drugs referring to Clinical Toxicology Department of Noor University Hospital, Isfahan, Iran. The clinical signs and symptoms and the vital signs at the admission time were measured, and the required therapies were given. The endotracheal intubation was done for patients who had the indication of intubation. BIS was monitored and compared for all patients with or without a need for intubation on the admission time and time of endotracheal intubation. Obtained data were analyzed by SPSS software. FINDINGS: At the admission time, the mean (standard error [SE]) BIS index value for poisoned patients who needed endotracheal intubation was 66.47 ± 2.57 in comparison with 85.21 ± 1.47 for patients who did not need intubation (P < 0.001). The results of receiver operating characteristic curve (mean ± SE) showed the discrimination was excellent for BIS (0.899 ± 0.04; 95% confidence interval: 0.81-0.98) (P < 0.0001). BIS <79.5 had the sensitivity 88% and specificity 87% for endotracheal intubation. CONCLUSION: BIS is an appropriate index for prediction of the need to intubation in poisoned patients with ingestion of different drugs.

A randomized controlled trial comparing the effect of intravenous, subcutaneous, and intranasal fentanyl for pain management in patients undergoing cesarean section.

BACKGROUND: The objective of this study was to evaluate and compare the effects of three methods of using intravenous (IV), subcutaneous and intranasal (IN) fentanyl for pain management following general anesthesia in patients undergoing cesarean section. MATERIALS AND METHODS: A prospective, randomized, single-blind clinical trial was done on 75 patients aged 20-40 years, American Society of Anesthesiology-1, who had a normal singleton pregnancy beyond 36 weeks of gestational age. Patients were randomized to receive 50 µg fentanyl intravenously (Group 1), subcutaneously (Group 2) or intranasally (Group 3) after closure of incision. The pain intensity, nausea, the systolic, and diastolic blood pressures were assessed. RESULTS: All groups were equivalent for baseline characteristics. The average pain visual analog scale (VAS) score was less in the second group who received fentanyl subcutaneously at the time of recovery admission (6.8 ± 1.5) (P = 0.037) and after 3 h (6.36 ± 1.5) (P = 0.033) postoperatively. The mean VAS score of nausea and the mean systolic and diastolic blood pressures were not significantly different between three groups throughout the study (P > 0.05). CONCLUSION: subcutaneous fentanyl is an effective alternative to IV and IN route of administration for pain management.

Preventive effect of ilioinguinal nerve block on postoperative pain after cesarean section.

BACKGROUND: Cesarean section is a major operation that can be the predictor of postoperative pain and discomfort and, therefore, providing the effective postoperative analgesia is an important factor to facilitate sooner movement of the patient, better care of infants. The aim of this study was to determine the preventive effect of ilioinguinal nerve block on pain after cesarean section. MATERIALS AND METHODS: In a randomized clinical trial study, 80 female candidates for cesarean section under general anesthesia were selected and divided into two groups. In the first group, ilioinguinal nerve was blocked and in the control group, ilioinguinal nerve block was not done. Finally, postoperative pain was compared between the two groups. RESULTS: The mean pain intensity at 6 and 24 h after operation had no significant difference between two groups but in the rest of the times, it was different between two groups. Furthermore, in sitting position, except for 6 h, the pain intensity at the rest of the time had a significant difference between two groups. The pain intensity in 12 h after operation had a significant difference while in 24 h after operation; there was no difference between two groups. Doing repeated measures, ANOVA also indicated that the process of changes in the pain intensity in three positions of rest, sitting and walking had no significant difference up to 24 h after operation (P < 0.001). CONCLUSION: Control of pain after cesarean as one of the most common factors for abdominal surgery will lead to decrease the staying of the patient in hospital, reduce morbidity and lower use of narcotics and analgesics after surgery.

Effects of different anesthetic techniques on neurologic and adaptation capacity in newborn with elective cesarean section.

BACKGROUND: Neurologic and Adaptive Capacity Scoring (NACS) has been introduced as a screening test for diagnosis of central nervous system depression due to intrapartum drugs on the neonate. This test can show neurological and behavioral changes even in the presence of a normal Apgar score. NACS has 20 indicators, each indicator allocating to itself the score zero, one or two. The aim of this study was to compare the effects of different anesthetic techniques on the NACS values. MATERIALS AND METHODS: This study was performed as a randomized, single-blind clinical trial on 75 infants born with elective cesarean in Shahid Beheshti Hospital, Isfahan. Simple Sampling method was carried out and the information was gathered by questionnaires. Anesthetic techniques included general, spinal or epidural anesthesia. NACS score was assessed at 15(th) min, 2 and 24 h after birth and then the anesthesia technique was recorded in the questionnaire. NACS score 35 or above was considered normal and 34 or less was abnormal. RESULTS: In the present study, no significant correlation was found between the anesthesia techniques and NACS score. The mean NACS at 15 min after birthin the general, spinal and epidural groups were 33.5 ± 2.2, 33.0 ± 4.4 and 33.7 ± 1.6 respectively (P = 0.703). CONCLUSION: All three anesthetic techniques have identical effects on neurological and compatibility capacity of neonates born with elective cesarean; so, this could necessarily be a base to recommend the three methods equally.

The effect of preemptive pudendal nerve block on pain after anterior and posterior vaginal repair.

INTRODUCTION: Anterior and posterior vaginal repair (APR) is a common surgery for women with prolapse of pelvic organs which creates post-operative pain because of damage of tissues that we should manage and control this pain. For this purpose, this study was conducted in order to evaluate the effect of preemptive pudendal nerve block on post-operative pain in anterior and posterior vaginal wall repair. MATERIALS AND METHODS: In a double-blinded clinical trial study, 60 women candidates of APR were randomly divided to two groups. In both of them was injected 0.3 cc/kg bupivacaine 0.25% for the intervention group or normal saline for the control group in pudendal nerve tract with the guide of nerve stimulator. A visual analog scale was used to measure pain during the first 48 h after the surgery. Data were analyzed by repeated measures analysis of variance (ANOVA). RESULTS: Compared with the intervention group, the control group experienced greater pain during rest and walking. There were significant differences between the two groups from the first post-operative hour (P = 0.003) until 48 h after the operation (P = 0.021). Furthermore, the mean ± SD values of pain in the sitting position was not significantly different between control and intervention groups at the same time (P = 0.340). CONCLUSION: Preemptive pudendal nerve block can reduce post-operative pain score in anterior and posterior vaginal wall repair and this method was suggested in anterior and posterior vaginal wall repair.

Evaluation of the analgesic effect of subcutaneous methadone after cesarean section.

BACKGROUND: Inadequate pain control has a significant role in maternal and neonatal health in early post-partum period which interferes with breastfeeding and has a negative influence on child normal growth. The aim of this study is evaluation of subcutaneous methadone effectiveness on post-operative pain control. MATERIALS AND METHODS: Double blind randomized prospective clinical trial involving 60 term pregnancy patients through 2008 to 2009 Undergo cesarean. INCLUSION CRITERIA: Prime gravid candidate of elective cesarean and spinal anesthesia class 1 or 2. Known case of drug allergy and methadone interaction, addiction, uncontrolled medical disease excluded. Case group injected 10 mg of subcutaneous methadone in the site of incision before final suture. Morphine was a pain reliever in follow up examination. Data include mean of pain, nausea and vomiting, MAP, etc., collected and analyzed by independent-T test and Man Whitney test. RESULTS: Although mean usage of morphine between groups was not significant statistically but the mean pain severity (P value < 0.05) and mean satisfactory (P value = 0.02) was statistically significant between groups. Other parameters were not statistically significant. CONCLUSION: We suggest subcutaneous methadone as a safe pain reliever in post cesarean section patients.

The predictive value of the ratio of neck circumference to thyromental distance in comparison with four predictive tests for difficult laryngoscopy in obstetric patients scheduled for caesarean delivery.

BACKGROUND: Preoperative assessment of anatomical landmarks andclinical factors help detect potentially difficult laryngoscopies. The aim of the present study was to compare the ability to predict difficult visualization of the larynx from thefollowing preoperative airway predictive indices, in isolation and combination: Neck circumference to thyromental distance (NC/TMD), neck circumference (NC), modified Mallampatitest (MMT), the ratio of height to thyromental distance (RHTMD), and the upper-lip-bite test (ULBT). MATERIALS AND METHODS: We collected data on657 consecutive patients scheduled for elective caesarean delivery under general anesthesia requiring endotracheal intubation and then evaluated all five factors before caesarean. An experienced anesthesiologist, not informed of the recorded preoperative airway evaluation, performed the laryngoscopy and grading (as per Cormack and Lehane's classification). Sensitivity, specificity, and positive and negative predictive values for each airway predictor in isolation and in combination were determined. RESULTS: Difficult laryngoscopy (Grade 3 or 4) occurred in 53 (8.06%) patients. There were significant differences in thyromental distance (TMD), RHTMD, NC, and NC/TMD between difficult visualization of larynx and easy visualization of larynx patients (P < 0.05). The main end-point area under curve (AUC) of the receiver-operating characteristic (ROC) was lower for MMT (AUC = 0.497; 95% Confidence Interval = CI,0.045-0.536) and ULBT (AUC = 0.500, 95% CI, 0.461-0.539) compared to RHTMD, NC, TMD, and NC/TMD score ([AUC = 0.627, 95% CI, 0.589-0.664], [AUC = 0.691; 95% CI, 0.654-0.726], [AUC = 0.606; 95% CI, 0.567-0.643], [AUC = 0.689;95% CI, 0.625-0.724], respectively), and the differences of six ROC curves were statistically significant (P < 0.05). CONCLUSION: The NC/TM Discomparable with NC, RHTMD, and ULBT for the prediction of difficult laryngoscopy in caes are an delivery.

Prediction of endotracheal intubation outcome in opioid-poisoned patients: A clinical approach to bispectral monitoring.

BACKGROUND: Some opioid-poisoned patients do not respond appropriately to naloxone; consequently, intubation is required. Although various measures have been used to evaluate the level of consciousness of poisoned patients, no study has assessed the role of the bispectral index (BIS) to ascertain the depth of anesthesia in opioid-poisoned patients who require endotracheal intubation. OBJECTIVE: To compare BIS scores between opioid-poisoned patients with and without intubation, and to determine the BIS cut-off point for endotracheal intubation in these patients. METHODS: In the present cross-sectional study, conducted in an Iranian university referral hospital for poisoning emergencies between 2012 and 2013, opioid-poisoned patients (n=41) were divided into two groups according to their requirement for endotracheal intubation. BIS analyses were performed at the time of admission and at the time of intubation for those who required it. In addition, electromyography and signal quality index were evaluated for all patients at the time of admission, and cardiorespiratory monitoring was performed during the hospitalization period. Using ROC curves, and sensitivity and specificity analyses, the optimal BIS cut-off point for prediction of intubation of these patients was determined. RESULTS: The optimal cut-off point for prediction of intubation was BIS ≤78, which had a sensitivity of 86.7% (95% CI 66.1 to 98.8) and specificity of 88.5% (95% CI 73.9% to 98.8%); the positive and negative predictive values were 81.2 % and 92%, respectively. CONCLUSIONS: BIS may be considered an acceptable index to determine the need for intubation in opioid-poisoned patients whose response to naloxone is inadequate.

HISTORIQUE: Certains patients empoisonnés par des opioïdes ne répondent pas bien au naloxone et doivent être intubés. Diverses mesures sont utilisées pour évaluer le niveau de conscience des patients empoisonnés, mais aucune étude n'a porté sur le rôle de l'index bispectral (IBS) pour déterminer la profondeur de l'anesthésie chez les patients empoisonnés par des opioïdes qui doivent subir une intubation trachéale. OBJECTIF: Comparer les indices de l'IBS entre les patients empoisonnés par des opioïdes intubés ou non et déterminer le seuil d'IBS pour l'intubation trachéale de ces patients. MÉTHODOLOGIE: Dans la présente étude transversale menée entre 2012 et 2013 dans un hôpital universitaire iranien spécialisé dans les urgences causées par des empoisonnements, les patients empoisonnés par des opioïdes (n=41) ont été divisés en deux groupes, en fonction de la nécessité qu'ils subissent une intubation trachéale. Les chercheurs ont analysé l'IBS au moment de l'admission et de l'intubation des patients qui devaient la subir. Ils ont aussi évalué l'électromyographie et l'indice de qualité du signal chez tous les patients au moment de l'admission et assuré un monitorage cardiorespiratoire pendant la période d'hospitalisation. À l'aide des courbes ROC et des analyses de sensibilité et de spécificité, ils ont déterminé le seuil d'IBS optimal pour prédire l'intubation de ces patients. RÉSULTATS: Un IBS de 78 ou moins, d'une sensibilité de 86,7 % (95 % IC 66,1 à 98,8) et d'une spécificité de 88,5 % (95 % IC 73,9 % à 98,8 %), était le seuil optimal pour prédire l'intubation. Les valeurs prédictives positives et négatives s'établissaient à 81,2 % et 92 %, respectivement. CONCLUSIONS: L'IBS peut être considéré comme un index acceptable pour déterminer la nécessité d'intuber les patients empoisonnés par des opioïdes qui répondent peu au naloxone.

Preemptive subcutaneous tramadol for post-operative pain in lower abdomen surgeries: A randomized double blinded placebo-control study.

BACKGROUND: Recently, the preemptive analgesic effects of subcutaneous infiltration of tramadol (T) in the site of incision have not been extensively studied. In this study, we investigated the effect of subcutaneous T infiltration before the incision of surgery on post-operative pain, in lower abdomen surgeries. MATERIALS AND METHODS: This double-blind study was carried out on 90 patients (18-65 years) of American Society Anesthesiologists physical status I and II who were candidates for a lower abdomen surgery during 2011. They were randomly assigned to receive preemptive subcutaneous T or normal saline (NS). The visual analogue scale for pain (VAS) in rest and cough position and opium total dose consumption were compared between two groups in times 0, 15, 30, 60 min and 2, 4, 6, 12, 24 h after the surgery. RESULTS: The VAS in cough and rest position in the first 24 h following the surgery was lower in group T (P < 0.05). Opium consumption was lower in group T (P < 0.05). CONCLUSION: Subcutaneous preemptive infiltration of T before surgical incision reduces post-operative opioid consumption.

The effect of intravenous Dexamethasone on post-cesarean section pain and vital signs: A double-blind randomized clinical trial.

OBJECTIVE: Any operation leads to body stress and tissue injury that causes pain and its complications. Glucocorticoids such as Dexamethasone are strong anti-inflammatory agents, which can be used for a short time post-operative pain control in various surgeries. Main purpose of this study is to evaluate the effect of administration of intravenous (IV) Dexamethasone on reducing the pain after cesarean. METHODS: A double-blind prospective randomized clinical trial was performed on 60 patients candidate for elective caesarean section. Patients were randomly assigned into two groups: A (treatment: 8 mg IV Dexamethasone) and B (control: 2 mL normal saline). In both groups, variables such as mean arterial blood pressure (MAP), heart rate (HR), respiratory rate (RR), pain and vomiting severity (based on visual analog scale) were recorded in different time points during first 24 h after operation. Statistical methods using repeated measure analysis of variances and t-test, Mann-Whitney and Chi-square tests were used for analyzing data. FINDINGS: The results indicated that within-group comparisons including severity of pain, MAP, RR and HR have significant differences (P < 0.001 for all variables) during the study period. Between group comparisons indicated significant differences in terms of pain severity (P < 0.001), MAP (P = 0.048) and HR (P = 0.078; marginally significant), which in case group were lower than the control group. CONCLUSION: IV Dexamethasone could efficiently reduce post-operative pain severity and the need for analgesic consumption and improve vital signs after cesarean section.

Treatment of postoperative nausea and vomiting after spinal anesthesia for cesarean delivery: A randomized, double-blinded comparison of midazolam, ondansetron, and a combination.

BACKGROUND: The antiemetic efficacy of midazolam and ondansetron was shown before. The aim of the present study was to compare efficacy of using intravenous midazoalm, ondansetron, and midazolam in combination with ondansetron for treatment of nausea and vomiting after cesarean delivery in parturient underwent spinal anesthesia. MATERIALS AND METHODS: ONE HUNDRED THIRTY TWO PARTURIENTS WERE RANDOMLY ALLOCATED TO ONE OF THREE GROUPS: group M (n = 44) that received intravenous midazoalm 30 µg/kg; group O (n = 44) that received intravenous ondansetron 8 mg; group MO (n = 44) that received intravenous midazoalm 30 µg/kg combined with intravenous ondansetron 8 mg if patients had vomiting or VAS of nausea ≥ 3 during surgery (after umbilical cord clamping) and 24 hours after that. The incidence and severity of vomiting episodes and nausea with visual analog scale (VAS) > 3 were evaluated at 2 hours, 6 hours, and 24 hours after injection of study drugs. RESULTS: The incidence of nausea was significantly less in group MO compared with group M and group O at 6 hours postoperatively (P = 0.01). This variable was not significantly different in three groups at 2 hours and 24 hours after operation. The severity of nausea and vomiting was significantly different in three groups at 6 hours after operation (P < 0.05). CONCLUSION: Our study showed that using intravenous midazolam 30 µg/kg in combination with intravenous ondansetron 8 mg was superior to administering single drug in treatment of emetic symptoms after cesarean delivery under spinal anesthesia.

Adding different doses of intrathecal magnesium sulfate for spinal anesthesia in the cesarean section: A prospective double blind randomized trial.

BACKGROUND: There is uncertainty as to whether addition of magnesium sulfate to spinal local anesthetics improves quality and duration of block in the caesarean section. In this randomized double blind clinical trial study, we investigated the effect of adding different doses of intrathecal magnesium sulfate to bupivacaine in the caesarean section. MATERIALS AND METHODS: After institutional approval and obtaining informed patient consent, 132 ASA physical status I-II women undergoing elective cesarean section with spinal anesthesia were randomized to four groups: 1 - 2.5 cc Bupivacaine 0.5%+ 0.2 cc normal saline (group C) 2 - 2.5 cc Bupivacaine 0.5%+ 0.1 cc normal saline+ 0.1 cc magnesium sulfate 50% (group M(50)) 3- 2.5 cc Bupivacaine 0.5%+ 0.05 cc normal saline+ 0.15 cc magnesium sulfate 50% (group M(75)) 4- 2.5 cc Bupivacaine 0.5%+ 0.2 cc magnesium sulfate 50% (group M(100)). Patients and staff involved in data collections were unaware of the patient group assignment. We recorded the following: onset and duration of block, time to complete motor block recovery, and analgesic requirement. RESULTS: Magnesium sulfate caused a delay in the onset of both sensory and motor blockade. The duration of sensory and motor block were longer in M(75) and M(100) groups than group C (P < 0.001). Recovery time was shorter in group C (P < 0.001) and analgesic requirement was more in group C than others (P < 0.001). CONCLUSIONS: In patients undergoing the caesarean section under hyperbaric bupivacaine spinal anesthesia, the addition of 50, 75, or 100 mg magnesium sulfate provides safe and effective anesthesia, but 75 mg of this drug was enough to lead a significant delay in the onset of both sensory and motor blockade, and prolonged the duration of sensory and motor blockade, without increasing major side effects.

Pain relief after cesarean section: Oral methadone vs. intramuscular pethidine.

BACKGROUND: Appropriate pain management is needed during the post-partum hospitalization period for preventing cesarean section (CS) related complications. Protocols of post-partum pain management should be planned based on the facilities of each center or region. The aim of current study was to compare the analgesic efficacy of oral methadone and intra muscular (IM) pethidine which the latter was routinely used in our center in post cesarean pain treatment. MATERIALS AND METHODS: In this prospective double-blind clinical trial, women who were candidate for cesarean section were selected and randomized into two groups. All patients routinely received a single IM pethidine dose (50 mg) after CS in the recovery room. One group of patients received 0.7 mg/kg pethidine every 6 hour IM, and another group received 0.07 mg/kg oral methadone every 6 hour. Severity of pain assessed using visual analogue scale (VAS) score in 6, 12, 18 and 24 hour after surgery. RESULTS: Pain severity in methadone group at 6, 12, 18 and 24 hour post operation were 6.4 ± 0.9, 3.4 ± 0.8, 1.9 ± 1.1, 0.5 ± 0.5 (p < 0.05) and for patients in pethidine group were 6.6 ± 0.8, 3.4 ± 0.9, 2.1 ± 1.0 and 0.5 ± 0.5 (p < 0.05), respectively (Mean ± SD). Between groups differences in each follow up time were not statistically significant. There was no difference between groups in terms of complications and supplementary analgesic use. CONCLUSION: Considering the similar analgesic effects of methadone and pethidine, satisfaction of patients and nursing system with methadone use and the cost benefit of methadone, it can be recommended to use methadone for post operative pain relieving.

The effects of hyperbaric or isobaric bupivacaine on bispectral index in spinal anesthesia for cesarean section.

BACKGROUND: Hyperbaric and isobaric bupivacaine has been shown to reduce bispectral index (BIS) during spinal anesthesia. The aim of this study was to compare the effect of isobaric bupivacaine and hyperbaric bupivacaine on the BIS during cesarean section with spinal anesthesia. MATERIALS AND METHODS: In this double-blind randomized controlled clinical trial, 84 pregnant women with ASA (American Society of Anesthesiologists) class I or II were randomly assigned to receive isobaric or hyperbaric bupivacaine. BIS was measured using electro encephalography (EEG) and recorded at the baseline and 5th, 10th, 15th, 30th, 45th, 60th, 90th and 120th minutes after spinal injection. The heart rate (HR), mean arterial pressure (MAP), signal quality index (SQI), electromyography (EMG) and the temperature were also recorded during surgery. RESULTS: From recruited subjects, 41 completed the study in each group and their data were analyzed. The BIS score began to reduce until 30(th) minute for isobaric bupivacaine and 45(th) minute for hyperbaric bupivacaine after spinal injection. The recorded BIS was not significantly different between two groups at all the time points. Difference of BIS from baseline was not significant between two groups at most time points except for the 45(th) minute after injection that it was 5.9 ± 9 vs. 2.7 ± 4.6 for hyperbaric and isobaric bupivacaine, respectively (p = 0.047). The changing trend was not significantly different between groups with hyperbaric and isobaric bupivacaine. CONCLUSION: According to the present study, the BIS score during surgery began to decrease when the patients were injected spinally by both of these drugs. The greatest decrease from baseline BIS values occurred at 30 and 45 minutes after induction of spinal anesthesia. However, hyperbaric or isobaric bupivacaine did not have different effects on the BIS during spinal anesthesia.

Prevention of post-spinal hypotension using crystalloid, colloid and ephedrine with three different combinations: A double blind randomized study.

BACKGROUND: The benefit of prophylactic combination therapy using crystalloid and colloid preload with ephedrine has not been cleared to prevent maternal hypotension after spinal anesthesia at cesarean delivery. This study evaluated the efficacy of three combinational methods to prevent hypotension following spinal anesthesia. MATERIALS AND METHODS: In this prospective double blind trial, 150 candidates of elective cesarean delivery under spinal anesthesia were randomly allocated to three treatment groups; 1---Ringer's Lactate (RL) solution (15 ml/kg) plus Hemaxel (7 ml/kg) preload, 2---RL solution (15 ml/kg) preload plus ephedrine (15 mg, IV, bolus), 3---Hemaxel (7 ml/kg) preload plus ephedrine (15 mg, IV, bolus). Maternal hemodynamic changes during 60 min after spinal injection, nausea/vomiting, and neonatal condition were compared among the groups. RESULTS: The cumulative incidence of hypotension was 44%, 40%, and 46% in groups 1 to 3, respectively. There were not significant differences in supplementary ephedrine requirement among groups which received or among groups which did not receive prophylactic ephedrine. Groups were not different in the incidence of hypertension and nausea or vomiting. There were no significant differences among groups in Apgar scores at 1 or 5 min and umbilical artery PH. CONCLUSION: Combination of preventive methods decreased the occurrence of hypotension following spinal anesthesia to an acceptable level. Overall, the most effective method was a combination of crystalloid preload with ephedrine.

The comparison of intraincisional injection tramadol, pethidine and bupivacaine on postcesarean section pain relief under spinal anesthesia.

BACKGROUND: Bupivacaine, tramadol, and pethidine has local anesthetic effect. The aim of this study was to compare effect of subcutaneous (SC) infiltration of tramadol, pethidine, and bupivacaine on postoperative pain relief after cesarean delivery. MATERIALS AND METHODS: 120 patient, scheduled for elective cesarean section under spinal anesthesia, were randomly allocated to 1 of the 4 groups according to the drugs used for postoperative analgesia: Group P (Pethidine) 50 mg ,Group T (Tramadol) 40 mg, Group B (Bupivacaine 0.25%) 0.7 mg/kg, and Group C (control) 20CC normal saline injection in incision site of surgery. Pain intensity (VAS = visual analogous scale) at rest and on coughing and opioid consumption were assessed on arrival in the recovery room, and then 15, 30, 60 minutes and 2, 6, 12, 24 hours after that. RESULTS: VAS scores were significantly lower in groups T and P compared with groups B and C except for 24 hours (VAS rest) and 6 hours (VAS on coughing) postoperatively (P < 0.05). The number of patients requiring morphine were significantly different between the groups (105 doses vs. 87, 56, 46, doses for group C, B, T and P, respectively, P < 0.05) in all the times, except for 2 and 6 hours postoperatively. CONCLUSIONS: The administration of subcutaneous pethidine or tramadol after cesarean section improves analgesia and has a significant morphine-sparing effect compared with bupivacaine and control groups.

A comparison of the effects of fentanyl and remifentanil on nausea, vomiting, and pain after cesarean section.

BACKGROUND: The effects of different opioids on postoperative nausea and vomiting (PONV) and pain have not been conclusively determined. The aim of this study was to compare the effects of fentanyl, remifentanil or fentanyl plus morphine on the incidence of PONV and pain in women subjected to cesarean section under general anesthesia. METHODS: The study was a randomized clinical trial recruiting 96 parturients with American Society of Anesthesiologists (ASA) physical status I and II. They scheduled for cesarean section under general anesthesia using sodium thiopental, succynylcholine, and isoflurane O2/N2O 50/50 mixture. After clamping the umbilical cord, the patients were given fentanyl (2 µg/kg/h), remifentanil (0.05 µg/kg/h), or fentanyl (2 µg/kg) pulse morphine (0.1 mg/kg) intravenously. Visual analog scale for pain and nausea, frequency of PONV, meperidine and metoclopramide consumption were evaluated at recovery, and 4, 8, 12 and 24 hours after the surgery. RESULTS: There was no significant difference between the three groups in terms of frequency of nausea, vomiting, and mean nausea and pain scores at any time points. None of the patients required the administration of metoclopramide. However, the mean VAS for pain in remifentanil-treated group was insignificantly more than that in fentanyl- or fentanyl plus morphine-treated group at recovery or 4 hours after the surgery. The mean mepridine consumption in remifentanil-treated group was significantly (P=0.001) more than that in fentanyl- or fentanyl plus morphine-treated group in 24 hours after the surgery respectively. There was no significant difference in hemodynamic parameters of the three groups in all measurements after the surgery. CONCLUSION: The findings of this study showed that early postoperative analgesia was better with fentanyl, and postoperative meperidine consumption was significantly less with fentanyl than with remifentanil or combined fentayl and morphine.

A randomized comparative trial of combinational methods for preventing post-spinal hypotension at elective cesarean delivery.

BACKGROUND: Various methods have been applied to prevent maternal hypotension after spinal anesthesia for cesarean delivery. We compared the efficacy of three combinational methods in this regard in the current study. METHODS: In this randomized comparative trial, 150 candidates of elective cesarean delivery under spinal anesthesia were assigned to three groups: crystalloid preload and leg bandage, colloid preload and leg bandage, and ephedrine and leg bandage. Maternal hemodynamic changes during 60 minutes after spinal injection and neonatal condition were compared among the groups. RESULTS: The cumulative incidence of hypotension was 54%, 64%, and 36% in groups 1 to 3, respectively (p = 0.018). Spinal injection to hypotension interval was similar among the groups (p = 0.828). Heart rate in group 3 was significantly lower at the most time measures after anesthesia compared with the other two groups (p < 0.05 to <0.001). Regarding neonatal outcomes, the interval between the birth and the first breath was longer and the Apgar score at minute 1 was lower in group 3 compared with the other groups (p < 0.001 and 0.038, respectively) but it was not clinically important. Umbilical cord blood pH was similar among the three groups (p = 0.248). CONCLUSIONS: Among the three studied methods, administration of ephedrine plus bandage of the lower extremities was the most effective one in reducing the incidence of post-spinal hypotension. The groups were not clinically different concerning the effect of treatment on newborn health.