Comparison of the Effects of Magnesium Sulfate and Remifentanil on Hemodynamic Responses During Tracheal Extubation After Laparotomy: A Randomized Double-blinded Trial.

BACKGROUND: Because blood pressure and heart rate (HR) elevations during tracheal extubation are common, different medications have been studied to prevent such complications. OBJECTIVES: To compare magnesium sulfate, remifentanil, and placebo regarding mean arterial pressure (MAP) and HR changes during/after tracheal extubation, in patients who underwent laparotomy. MATERIALS AND METHODS: In this randomized double-blinded trial, 120 patients undergoing laparotomy were evenly divided into three groups, including remifentanil (1 mcg/kg), magnesium sulfate (50 mg/kg), or normal saline, as placebo. Hemodynamic responses (MAP and HR) were documented at different times (before operation, during medication administration, immediately before extubation, immediately after extubation, and also 3, 5, and 10 minutes after extubation). The double burst time (DBT) was determined using neuromuscular monitoring, as time interval, between administration of reverse medication and DBT of 100%. RESULTS: The HR was significantly lower, immediately after extubation and 3, 5, and 10 minutes after extubation, in both magnesium and remifentanil groups, compared to normal saline (P < 0.001). The MAP was also lower in magnesium and remifentanil groups, immediately after extubation and 3 minutes after extubation, in comparison to the normal saline group (P < 0.001). Mean (± SD) DBT 100% was significantly higher in magnesium group (30.2 ± 15.3) vs. remifenatnil (13.6 ± 6.8) and normal saline (13.5 ± 8.2) groups (P < 0.001). CONCLUSIONS: Both remifentanil and magnesium had favorable outcomes in preventing HR and MAP elevation after tracheal extubation. However, remifentanil was associated with more rapid regaining of consciousness and reversal of muscular relaxation.

Efficacy of transversus abdominis plane block for acute postoperative pain relief in kidney recipients: a double-blinded clinical trial.

BACKGROUND: After renal transplantation, postoperative pain is usually mild to moderate. Postoperative pain is a concern and administration of systemic analgesic may be difficult because of underlying co-morbidities and variable responses of the graft. The transversus abdominis plane (TAP) block is one of the different approaches for postoperative pain relief following abdominal surgeries. We evaluated analgesic efficacy of TAP block on early postoperative pain by numeric rating scale (NRS) and morphine consumption during the first 24 hours after kidney transplantation. METHODS: Forty-four patients, scheduled as kidney recipients were randomized into two equal groups and were anesthetized with the same technique. After the induction of anesthesia, 15 mL of 0.25% Bupivacaine plus 5 µ/ml epinephrine or saline was deposited into the transversus abdominis neuro-fascial plane on the side of surgery by ultrasound guide. Each patient was assessed by a blinded investigator using NRS at 1st, 4th, 8th, 12th, and 24th hour postoperatively. RESULTS: Demographic data were not significantly different between the study groups. There was significant difference in median of NRS score measured at all time points in the study groups (P < 0.001). The 24-hour morphine consumption (mean ± SD) was 10.8 ± 9.5 mg in bupivacaine group compared with 41.2 ± 3.8 mg in the saline group (P = 0.001). There was statistically significant reduction in intraoperative fentanyl consumption in the TAP group 120 ± 20 µg compared to the control group 358 ± 24 µg (P = 0.001). In study group 4 patients and in control group 90 patients received morphine titration for pain relief (P = 0.03). There was no complication in the study groups related to nerve block. Only two patients in saline group had nausea (P = 0.07). None of our patients received any other oral or IV rescue medication. CONCLUSION: Ultrasound TAP block can reduce postrenal transplantation pain and the amount of opioids consumption intraoperatively and during the first 24 hours after surgery in kidney recipients.

Efficacy of the valsalva maneuver on needle projection pain and hemodynamic responses during spinal puncture.

This study evaluated the efficacy of the valsalva maneuver that can induce baroreceptor activation and nociception, on needle projection pain and hemodynamic responses associated with spinal puncture. Ninety adults, ASA physical status I and II undergoing elective surgeries were included. Patients were randomized into three equal groups. Group I (C): control; Group II (B): ball; pressed a rubber ball (attention-diverting method); Group III (V): valsalva; blew into sphygmomanometer tubing and hold the mercury column up to 30 mm Hg for a period of at least 20s. Spinal needle projection pain was graded using numeric rating scale (NRS): 1-10, where scales of 1-3 were rated as mild, 4-6 as moderate, and >6 as severe. Blood pressure and heart rate, five minutes before the procedure, during the spinal puncture and first and third minutes after that, were also recorded. Significant reduction in NRS was observed in the valsalva group compared with the control and the ball groups (p=0.001). There were statistical but no significant clinical differences in mean arterial blood pressure and heart rates between the study groups (P=0.008 and P=0.016 respectively). In conclusion valsalva maneuver can decrease the skin puncture pain associated with spinal needle projection while observing hemodynamic changes.

The efficacy of ilioinguinal-iliohypogastric and intercostal nerve co-blockade for postoperative pain relief in kidney recipients.

BACKGROUND: Postoperative pain is severe in patients undergoing renal transplantation. Systemic analgesia may produce complications as a result of impaired renal function. We investigated whether combined lower intercostal and Ilioinguinal-Iliohypogastric (IG-IH) nerve block might improve the quality of analgesia and reduce morphine consumption during the first 24 h after surgery. METHODS: Forty-two patients, scheduled as kidney transplant recipients were randomized into two equal groups and were anesthetized with the same technique. After surgery IG-IH, T11 and T12 intercostal nerves on the side of surgery were blocked by bupivacaine 0.5%. The control group was not blocked. Postoperative pain and total amount of morphine consumption were recorded by a person who was blinded to the allocation. RESULTS: There were significant differences in median visual analog scale scores (25th-75th) measurements at all time points in the study groups (P < 0.05). The total amount of morphine consumption during 24 h was 12.7 +/- 10.5 mg in the blocked group compared with 34.9 +/- 5.9 mg in the nonblocked group (P < 0.001). CONCLUSIONS: Combined IG-IH and lower intercostal nerves blockade after renal transplantation significantly reduced postoperative pain and opioid consumption.