The effect of erector spinae plane block on the use of anesthetic medications in lumbar spine surgery.

OBJECTIVES: To reduce the drug side effects and facilitate the emergence from anesthesia after complex spine surgery, various methods have been proposed. One of these methods is ESPB, which has been less studied. Hence, we conducted this study to evaluate the effectiveness of ESPB on the use of anesthetic drugs in lumbar spine surgery. METHODS: In this study, 70 patients undergoing lumbar spine fusion surgery were studied. Patients were randomly divided into two groups: the case group (n=35), in which bilateral ESPB was done, and the control group (n=35). After standard anesthesia protocols, anesthesia was maintained with isoflurane in both groups. Intraoperative isoflurane and perioperative opioid consumption were recorded. Statistical analysis was performed using SPSS software version 21. RESULTS: Intraoperative use of fentanyl in the case group was significantly lower than the control group (14.29±21.5 vs. 65.96±73.33 µg, p<0.001). Furthermore, isoflurane consumption in the intervention group compared to the controls was significantly lower (20.71±5.02 versus 28.83±8.68 mL, p<0.001). Moreover, the emergence time was significantly shorter in the case group than in the control group (8.49±4.30 minutes versus 15.00±4.94, p<0.001). In the post-anesthesia care unit 1 h after surgery, the pain scores in the case group were significantly lower than the controls (p<0.001). CONCLUSION: ESPB under ultrasound guidance is an effective method of regional anesthesia/analgesia for lumbar spine surgery (fusion) by decreasing the consumption of anesthetics during and following the surgery.

Presentation of Two Simple Methods to Confirm Proper Tracheal Intubation: Palm Pressure, Plastic Bag Inflation, and Bag Pulsation.

Background: The correct placement of the endotracheal tube is a cornerstone of safe anesthesia. Different methods, such as auscultation, capnography, and ultrasound, have their own limitations regarding the confirmation of endotracheal intubation, reinforcing the idea that a single technique is not foolproof. This study proposes a new technique in this regard. Materials and Methods: A total of 600 patients were enrolled in this study, and tracheal intubation was checked with palm pressure and disposable plastic glove inflation and pulsation. Results: The data were analyzed using the t-test and Mann-Whitney U test that indicate 94% and 94.8% sensitivity for palm pressure and bag pulsation, respectively, and a 100% positive predictive value for both tests. Conclusion: Palm pressure and bag pulsation are accurate, inexpensive, and reliable techniques to confirm proper tracheal intubation.

Evaluation of ultrasound guided erector spinae plane block efficacy on post operative pain in lumbar spine surgery: a randomized clinical trial.

OBJECTIVES: Patients suffer notable levels of pain after lumbar spine surgery. The primary objective of this randomized clinical trial is to investigate the efficacy of erector spinae plane block (ESPB) on 24-h post-operative pain score of patients undergoing lumbar spine surgery. Cumulative opioid consumption and intraoperative bleeding were assessed as well. METHODS: Adult patient candidates for elective lumbar spine surgery were randomly assigned to case (ESPB) and control (no ESPB) groups. The block was performed under ultrasound guidance in prone position after induction of general anesthesia. Both groups received the same anesthesia medication and technique. Post-operative pain score, number of patients requiring rescue analgesia (meperidine), total amount of post-operative rescue analgesic demand in the first 24 h, and intraoperative bleeding were recorded. To compare pain score variable in time span, the ANOVA repeated measure test was used. All the statistical tests were two tailed and p<0.05 considered as statistically significant. RESULTS: In all time intervals, pain score in case group was significantly lower than control group. In case group, eight patients demanded rescue analgesic (40%) which was significantly lower than that in control group (15 patients [75%]) (p=0.025). Total amount of meperidine consumption was 57.50±45.95 in control group and 22.50±32.34 in case group (p=0.01) which was higher in control group and statistically significant. CONCLUSION: ESPB reduces post-operative pain score and opioid consumption, while it does not affect intraoperative bleeding in lumbar spine surgery.

Loose Tooth, a Way to Save It: A Case Report.

A loose tooth is a great concern for anaesthesiologists either as a potential foreign body or a bleeding source. A 48-year-old male patient scheduled to undergo a lumbar discectomy had a loose maxillary incisor; he got his tooth fixed by using a thermoplastic external nasal splint. Different approaches such as modification in laryngoscopy or removal of loose teeth have been proposed, but fixing and keeping it in place is not a usual practice which was successfully applied for our patient. Loose incisors could be fixed and protected by using a thermoplastic nasal splint as a mouth guard.

The Predictive Power of Near-Infrared Spectroscopy in Improving Cognitive Problems in Patients Undergoing Brain Surgeries: A Systematic Review.

One of the main objectives in neurosurgical procedures is the prevention of cerebral ischemia and hypoxia leading to secondary brain injury. Different methods for early detection of intraoperative cerebral ischemia and hypoxia have been used. Near-infrared spectroscopy (NIRS) is a simple, non-invasive method for monitoring cerebral oxygenation increasingly used today. The aim of this study was to systematically review the brain monitoring with NIRS in neurosurgery. The search process resulted in the detection of 324 articles using valid keywords on the electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, the full texts of 34 studies were reviewed, and finally 11 articles (seven prospective studies, three retrospective studies, and one randomized controlled trial) published from 2005 to 2020 were identified as eligible for systematic review. Meta-analysis was not possible due to high heterogeneity in neurological and neurosurgical conditions of patients, expression of different clinical outcomes, and different standard reference tests in the studies reviewed. The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings.

The Role of Entrustable Professional Activities in Competency-based Medical Education for Anesthesiology Residents: A Pilot Phase.

Background: After graduation, physicians should be able to provide professional and safe services without the need for supervision by their clinical professors, mandating a competency-based medical education (CBME) approach. Objectives: This study aimed to develop a national model of entrustable professional activities (EPAs) based on our experiences in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU). Methods: The primary EPA design plan was designed in a 10-step model as a career roadmap for the project. The texts were prepared according to a consensus-based approach. On the other hand, the texts were reviewed and revised by a broad team of faculty in a daily workshop. Results: The final product included 14 topics for EPA as the first round of targeting topics for anesthesiology residents. The texts were developed using previous studies and were standardized considering national standards. Conclusions: We described a clear path toward designing and implementing EPAs in anesthesiology residency programs to improve the quality of the graduated residents. Though the basic theory is the same, each country needs its formula for implementing the process.

Assessment of Ratio of Height to Rhinion-Mentum Distance as a Predictive Tool for Difficult Tracheal Intubation.

Background: Difficult Intubation (DI) is a constant concern for anesthesiologists and being able to predict it will improve patient safety. Different tests have been presented in anesthesiology practice to increase the accuracy of the DI prediction. Since there is no single sensitive and specific test, most of the practitioners use a combination of them. Here we report a new and novel index of ratio of height to rhinion-mentum distance (RHRMD) to improve the prediction. Materials and Methods: Four hundred adult patients' candidate for elective surgery were enrolled into the study. Initially, patients' data such as weight, height and rhinion-mentum distance (RMD) were recorded by the first anesthesiologist. After anesthesia induction, the second anesthesiologist performed laryngoscopy and recorded the Cormack-Lehane (CL) score. CL score III or higher was considered as DI. Finally, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for RHRMD was calculated. Results: DI was reported in 7.75% of patients. RHRMD is related with CL grade: as the former increased, the latter decreased. RHRMD with cut-off point 25.4 has 90.6% sensitivity, 29.9% specificity, 10.1% PPV and 97.3% NPV in predicting DI. Conclusion: RHRMD with 90.6% sensitivity and 97.3% NPV could be a valuable tool for prediction of DI.

Residency Education Reform Program in Department of Anesthesiology and Critical Care: An Academic Reform Model.

BACKGROUND: Reform in medical education is a basic process in every academic department, especially in residency programs. OBJECTIVES: This study was designed to assess the indices of education and research as part of the Medical Education Reform program (MERP) in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU) for four years. METHODS: MERP in DACC, SBMU was designed and implemented as a modern academic reform model; different outcome measures in education and research were assessed to demonstrate the effects of the reform plan in academic improvements. RESULTS: there were significant improvements regarding education indices (i.e., teaching methods, passing comprehensive exams, mentorship, assessment methods, faculty development, professionalism in medical education, integration in education, and crisis management) and research indices (targeted research activities, innovation in research approaches, increasing the impact of research). CONCLUSIONS: Based on the experiences of DACC, SBMU regarding clinical anesthesiology residency, reform could be achieved using painstaking plans and continuous efforts with tangible documented outcomes. Often, the management period is not durable, and these reforms require meticulous care to sustain.

Fanconi Anaemia, What Anaesthesiologists Should Consider about.

Fanconi anaemia (FA) is a rare autosomal recessive inherited disease, which consists of bone marrow failure, skeletal deformities and multi organ nvolvement. Here, we report an emergency surgery on a FA patient with mucormycosis infection of paranasal sinuses. Since there are a few reports about FA, there is no general consensus on anaesthetic considerations so we deal with recommendations that are based on the pathology of FA. Possible difficult air way is the main concern, and low oxygen concentration and avoidance of nitrous oxide are among recommendations.

Hard and Granny Tie, Nasogastric Tube Knotted in Nasopharynx: A Case Report.

Nasogastric tubes are being used in clinical anaesthesia settings on a daily basis. Although rare, knotting could occur during insertion or removal. Here, we report a knotted nasogastric tube which stocked in patient's nasopharynx that was removed by using a pediatric bougie. Clinicians must be aware of potential knotting of nasogastric tube. Pediatric bougie could be utile if knotted tube gets stocked in nasopharynx.

Pulmonary Thromboembolism Following Spine Surgery: Clinical Suspicion is the Key.

Pulmonary thromboembolism following spine surgery, although rare, could end into devastating outcome. Gold standard for it diagnosis is pulmonary CT angiography but in operating theatre, clinical suspicion is the key to diagnose. Here we report a case of pulmonary embolism with classic clinical findings which approved using pulmonary CT angiography and echocardiography.

Tracheal Intubation Using Nelaton Catheter: A Simple Device, an Airway Rescue Option.

Although anticipated, difficult airway could turn into a catastrophe for health care providers, where planned strategies and equipment become useless. We report a challenging airway management process due to narrowed upper airway by the application of a Nelaton catheter as a rescue device.

Pitfalls in Ventilation Devices.

Adequate ventilation is the greatest concern of all the anaesthesiologists. Any disturbance in the ventilation process could result in serious hazards: hypoxemia or barotrauma. Deficient devices are one of many causes of such derangements. Some of the typical complications of airway/ventilation tools are described extensively in textbooks, but many other uncommon events can still occur. We described two interesting cases of device-related ventilation inadequacy, hoping that acquaintance with such jeopardizes would be helpful in emergency situations for other colleagues.

Leprosy, Ancient Disease and Modern Anaesthetic Considerations.

Leprosy is as old as mankind. Although rare, it could be seen in some parts of the world. Therefore, anaesthesiologists have to be familiar with its consequences and considerations that could pose as a challenge. Here, we report a case of leprosy that was referred to our hospital for debridement of his infected foot.

Effect of Intrapleural Meperidine on Post-Operative Pain after Open Cholecystectomy.

BACKGROUND: Post-operative pain after open cholecystectomy can result in increased oxygen consumption, atelectasis, pneumonia, decreased vital capacity, and increased morbidity and mortality. The aim of this study was to compare the analgesic effects of intrapleural meperidine and intravenous morphine in controlling post-cholecystectomy pain. MATERIALS AND METHODS: In a double-blinded randomized clinical trial, 72 patients who were candidate for elective open cholecystectomy, were divided randomly into two groups based on accidental randomized numbers. Anesthesia technique was precisely the same for all patients. At the end of surgery, 50 mg of meperidine (diluted in 20 cc normal saline) was injected intrapleurally for meperidine group patients; whereas, 0.1 mg/kg intravenous morphine was injected intravenously in control group. Onset of pain and total dose of rescue analgesic were measured. RESULTS: In order to obtain a Numerical Rating Scale (NRS) <3, the difference in morphine consumption up to 12 hours in two groups (4.4 ±1.7 mg in meperidine group & 5±2 mg in control group) was not statistically different. However, the first request for analgesia in meperidine group was delayed significantly longer than the control group (146.6 ±6.8 minutes in meperidine group & 40 ±1.8 minutes in control group). CONCLUSION: A single injection of intrapleural meperidine can delay the first request for analgesia in open cholecystectomy compared to intravenous morphine.

Foreign Body Stocked between Vocal Cords.

Foreign body (FB) aspiration is a rare event in adults and can mimic other pathologies such as refractory asthma. Most of the objects can be removed using a bronchoscope. Herein, we present a unique case of aspiration of a FB stocked between vocal cords for one week and the anesthetic considerations.