Effect of height versus height/weight-based spinal bupivacaine on maternal hemodynamics for elective cesarean in short stature patients: a randomized clinical trial.

PURPOSE: Doses of spinal bupivacaine adjusted to patient height or height/weight have been shown to provide hemodynamic stability during cesarean section. However, their effects in short stature parturients are unknown. METHODS: In this double-blind, randomized clinical trial, we randomly assigned short parturients (height < 150 cm) undergoing elective cesarean section, to receive doses of intrathecal hyperbaric bupivacaine either height or height/weight-adjusted, in a 1:1 ratio. The primary outcome was post-spinal hypotension (defined as systolic blood pressure [SBP] < 90% of baseline between spinal administration and delivery of the baby). Secondary outcomes included severe post-spinal hypotension (SBP < 80% of baseline), post-delivery hypotension (SBP < 90% and < 80% of baseline), intraoperative bradycardia, nausea and vomiting, shivering, rescue analgesic needed, and spinal block characteristics. RESULTS: A total of 112 patients underwent randomization. Post-spinal hypotension (SBP < 90% of baseline) occurred in 52% of the patients in the height/weight group and in 55% in the height group (difference - 3.5%: 95% confidence interval [CI] - 22 to 14.8, P = 0.705). There was no significant difference between the two groups in the occurrences of post-spinal severe hypotension (SBP < 80% of baseline), post-delivery hypotension, and spinal block characteristics. Six patients (11%) in the height/weight group needed intraoperative rescue analgesic compared to none in the height group (P = 0.027). CONCLUSION: We found that height-based dosing in short parturients provides the optimal trade-off between intraoperative hemodynamic instability and provision of pain-free anesthesia. TRIAL REGISTRATION: clinicaltrial.gov-NCT04082676. https://clinicaltrials.gov/ct2/show/NCT04082676 .

Intrathecal morphine does not prevent chronic postsurgical pain after elective Caesarean delivery: a randomised controlled trial.

BACKGROUND: Morphine is frequently added to spinal anaesthesia for Caesarean delivery. We aimed to determine whether intrathecal morphine for spinal anaesthesia decreases the risk of chronic postsurgical pain (CPSP). METHODS: In this randomised, double-blind, placebo-controlled trial, 290 healthy parturients undergoing elective Caesarean delivery were randomly assigned in a 1:1 ratio to receive either intrathecal morphine 100 µg (n=145) or normal saline (control; n=145) as a part of spinal anaesthesia. Anaesthetic care and postoperative pain management were standardised in all patients. The primary outcome was the incidence of CPSP at 3 months. Secondary outcomes included CPSP at 6 months, pain severity, and pain interference, measured by the Brief Pain Inventory questionnaire using an 11-point numeric rating scale, at 3 and 6 months after the surgery. RESULTS: Two hundred and seventy-six patients completed the 3-month follow-up, 139 in the morphine group and 137 in the placebo group. The incidences of CPSP at 3 months were 19% (27 of 139) in the morphine group and 18% (25 of 137) in the placebo group (odds ratio, 1.08; 95% confidence interval, 0.59-1.97; P=0.803). At 6 months, CPSP was present in 23 of 139 (16%) morphine group patients compared with 19 of 137 (14%) in the placebo group (odds ratio, 1.23; 95% confidence interval, 0.63-2.38; P=0.536). Brief Pain Inventory questionnaire scores for pain severity and pain interference at 3 and 6 months were similar between groups. CONCLUSIONS: Administration of morphine 100 µg as a component of spinal anaesthesia for elective Caesarean delivery failed to reduce the incidence of chronic pain at 3 and 6 months after surgery. CLINICAL TRIAL REGISTRATION: NCT03451695.

A case of hyperventilation leading to apnea and desaturation in PACU.

BACKGROUND: Respiratory adverse events are not uncommon in the post-anesthesia care unit (PACU) following general anesthesia. In this regard, hyperventilation leading to apnea and desaturation is a rare entity. Here we have reported a case of a 15-year-old girl who, following an uneventful general anesthesia, developed severe hyperventilation leading to apnea and desaturation in the PACU. CASE PRESENTATION: The 15-year-old girl underwent cortical mastoidectomy under general anesthesia. After a smooth anesthesia and an uneventful early recovery, she developed hyperventilation after about 15 min in the PACU. The symptom was severe enough to lead to apnea, desaturation and severe respiratory alkalosis. She required bag and mask ventilation and the symptoms resolved only transiently with propofol sedation. Finally, she responded to intravenous haloperidol and did not have any further episode after receiving haloperidol. CONCLUSION: Hyperventilation after a smooth recovery from anesthesia is not a common presentation. In this article we have tried to discuss the possible cause of such symptom in our patient and how we successfully managed this case. We have also proposed an algorithmic approach to diagnose and manage such cases in the PACU.

Chronic postsurgical pain: current evidence for prevention and management.

Chronic postsurgical pain (CPSP) is an unwanted adverse event in any operation. It leads to functional limitations and psychological trauma for patients, and leaves the operative team with feelings of failure and humiliation. Therefore, it is crucial that preventive strategies for CPSP are considered in high-risk operations. Various techniques have been implemented to reduce the risk with variable success. Identifying the risk factors for each patient and applying a timely preventive strategy may help patients avoid the distress of chronic pain. The preventive strategies include modification of the surgical technique, good pain control throughout the perioperative period, and preoperative psychological intervention focusing on the psychosocial and cognitive risk factors. Appropriate management of CPSP patients is also necessary to reduce their suffering. CPSP usually has a neuropathic pain component; therefore, the current recommendations are based on data on chronic neuropathic pain. Hence, voltage-dependent calcium channel antagonists, antidepressants, topical lidocaine and topical capsaicin are the main pharmacological treatments. Paracetamol, NSAIDs and weak opioids can be used according to symptom severity, but strong opioids should be used with great caution and are not recommended. Other drugs that may be helpful are ketamine, clonidine, and intravenous lidocaine infusion. For patients with failed pharmacological treatment, consideration should be given to pain interventions; examples include transcutaneous electrical nerve stimulation, botulinum toxin injections, pulsed radiofrequency, nerve blocks, nerve ablation, neuromodulation and surgical management. Physical therapy, cognitive behavioral therapy and lifestyle modifications are also useful for relieving the pain and distress experienced by CPSP patients.

Betamethasone gel compared with lidocaine jelly to reduce tracheal tube related postoperative airway symptoms: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Post-operative airway symptoms can be troublesome to patients following an uneventful general anesthesia with endotracheal intubation. In this study, we compared the effectiveness of lubricating an endotracheal tube with betamethasone gel or lidocaine jelly with using an unlubricated tube in reducing the incidence and severity of postoperative sore throat, hoarseness and cough. METHODS: This was a prospective, randomized, single-blind comparative study carried out among 120 ASA I and II patients aged 18-65 years undergoing elective surgery under general anesthesia with endotracheal intubation. Patients were randomly divided into three groups of 40 patients each. Endotracheal tube used for patients in group C was unlubricated, while that for group B and group L were lubricated up to 15 cm mark with 2.5 ml of 0.05% betamethasone gel or 2% lidocaine jelly respectively. Incidence and severity of postoperative sore throat, hoarseness and cough were observed at 1, 6 and 24 h following extubation. RESULTS: At 24 h following extubation, group B had the lowest incidence of postoperative sore throat among the three groups (group B: 12.5% vs group L: 37.5% vs group C: 25%; p = 0.036). Severity of postoperative sore throat at 24 h was less with betamethasone (score 0: 87.5%, 1: 10%) compared with lidocaine (score 0: 62.5%, 1: 37.5%) and control (score 0:75%, 1: 20%) (p = 0.006). Observations at other times and of other variables were comparable. CONCLUSION: Wide spread application of 0.05% betamethasone gel to lubricate the endotracheal tube significantly reduces the incidence and severity of sore throat at 24 h of extubation but not of hoarseness or cough.