Comparison of Dexmedetomidine and Dexamethasone as Adjuvants to Ultra-Sound Guided Interscalene Block in Arthroscopic Shoulder Surgery: A Double-Blinded Randomized Placebo-Controlled Study.

BACKGROUND: Interscalene block is one of the popular methods for decreasing pain and analgesic consumption after shoulder arthroscopic surgeries. OBJECTIVES: The objective is to compare the analgesic duration of effects of dexmedetomidine and dexamethasone as adjuvants to 0.5% ropivacaine in ultrasound-guided interscalene blocks for arthroscopic shoulder surgery in an ambulatory setting. METHODS: In this randomized controlled trial, 117 adult patients candidate for ambulatory arthroscopic shoulder surgery under general anesthesia were divided into three groups to perform an ultra-sound guided interscalene block before the surgery. The ropivacaine (control) group received ropivacaine 0.5% 20 mL, group Dexamethasone received ropivacaine 0.5% 20 mL plus 4mg dexamethasone, and group dexmedetomidine received ropivacaine 0.5% 20 mL plus 75 mcg of dexmedetomidine. Time to return of sensory function, of motor function, of first pain sensation, amount of opioid medication consumed at 24 hours and 48 hours post-operatively were measured. RESULTS: The 24-hour median (25th- 75th percentile) opioid consumption in morphine equivalents was similar between groups 22.5 mg (10 - 30), 15 mg (0 - 30), and 15 mg (0 - 20.6) in the ropivacaine, dexmedetomidine, and dexamethasone groups, respectively (P = 0.130). The median (25th- 75th percentile) 48 hours post-operatively, the median opioid consumption in morphine equivalents was 40 mg (25 - 67.5) in the ropivacaine group, 30 mg (22 - 50.6) in the dexamethasone group, and 52.5 mg (30 - 75) in the dexmedetomidine group (P = 0.278). The median 24-hour pain scores were 6 (5 - 8) in the ropivacaine control group, 7 (5.5 - 8) in the dexamethasone group, and 7 (4 - 9) in the dexmedetomidine group (P = 0.573). CONCLUSIONS: There was no statistical difference in opioid consumption at 24 and 48 hours post-operatively when comparing dexmedetomidine, dexamethasone, and no adjuvant. However, intraoperative opioid use was significantly lower with dexmedetomidine compared to dexamethasone and plain 0.5% ropivacaine. The safe side effect profile of dexmedetomidine makes it a reasonable alternative as an adjuvant for peripheral nerve blockade when dexamethasone use may be contraindicated.

Improved Pain Control with Combination Spinal Cord Stimulator Therapy Utilizing Sub-perception and Traditional Paresthesia Based Waveforms: A Pilot Study.

BACKGROUND: Chronic back and neck pain affects 20% of Americans. Spinal cord stimulation (SCS) is an effective therapy for otherwise refractory chronic pain. Traditional SCS relies on low-frequency stimulus in the 40 - 60 Hz range causing robust paresthesia in regions overlapping with painful dermatomes. OBJECTIVES: This study aims to determine the effect of superimposing sub-perception stimulation in patients who previously had good long-term relief with paresthesia. METHODS: This is a prospective observational trial examining patients who had previously been implanted with paresthesia based SCS for failed back surgery syndrome (FBSS) or complex regional pain syndrome (CRPS). These patients presented for implantable pulse generator (IPG) replacement based on battery depletion with an IPG capable of combined sub-perception and paresthesia based SCS therapy. Patients were assessed immediately following the exchange and four weeks later using a telephone survey. Their pain was assessed on each follow up using a Numerical Rating scale (NRS); the primary outcome was the change in NRS after four weeks from the exchange day. Secondary outcomes included paresthesia changes, which included the subjective quality of sensation generated, the overall subjective coverage of the painful region, subjective variation of coverage with positional changes, and global perception of the percentage improvement in pain. RESULTS: Based on our clinic registry, 30 patients were eligible for IPG exchange, 16 were consented for follow up and underwent an exchange, and 15 were available for follow up four weeks following. The average NRS decreased from 7.47 with traditional SCS to 4.5 with combination therapy. 80% of patients reported an improvement in the quality of paresthesia over traditional SCS therapy, and in most patients, this translated to significantly improved pain control. CONCLUSIONS: Our findings suggest improved pain relief in patients who had previously had good results with paresthesia based therapy and subsequently underwent IPG exchange to a device capable of delivering combined sub-perception stimulation. The mechanism of action is unclear though there may be an additive and/or synergistic effect of the two waveforms delivered. Larger studies with long-term follow-up are needed to elucidate the durability of pain relief and the precise mechanism by which combined subperception and paresthesia based SCS may improve overall patient outcomes.

Prevalence of Abnormal Methemoglobinemia and Its Determinants in Patients Receiving Nitroglycerin During Anesthesia.

BACKGROUND: One of the complications of nitroglycerin infusion during surgery is methemoglobinemia. OBJECTIVES: The aim of this study was to investigate the prevalence of methemoglobinemia and its association with nitroglycerin infusion for the treatment of hypertension during general anesthesia. METHODS: Patients received nitroglycerin infusion at a dose of 2 µ/kg/min. The aim of controlling blood pressure was to set the blood pressure at 20% of the patient's baseline. Then, the amount of methemoglobin was recorded at 15-minute intervals. Backward stepwise logistic regression test was used to determine the factors affecting methemoglobinemia. RESULTS: Based on the criterion of methemoglobin level above 2%, the prevalence of pathologic methemoglobinemia was 56.6%. After adjusting for confounding variables in the final model, the total prescribed dose was the only factor affecting pathologic methemoglobinemia. CONCLUSIONS: For the first time, we showed that more than half of the patients undergoing surgery suffered from methemoglobin level above 2% after prescribing nitroglycerin, and the only predictor of abnormal methemoglobin level was the rate of nitroglycerin prescription. Anesthesiologists are recommended to be more careful about the speed of nitroglycerin infusion, and if the patient needs higher doses, patient care for the early detection of methemoglobinemia should be the priority.

Comparison of the Effect of Intra-Rectal Administration of Lidocaine Gel and Lidocaine Plus Fentanyl on Pain Reduction in Prostate Biopsy: A Randomized Clinical Trial.

OBJECTIVES: The aim of this study was to compare the effect of intra-rectal administration of lidocaine gel alone versus lidocaine gel plus topical fentanyl on pain reduction in prostate biopsy. METHODS: In a double-blind randomized clinical trial, 96 patients who met the inclusion criteria were randomly assigned into two groups. 1) The treatment group: Lidocaine gel (2%) 50 g and 2) the intervention group: Lidocaine gel (2%) 50 g and fentanyl gel 50 µg. During the prostate biopsy, the VAS score was recorded. Blood pressure, heart rate, and patient level of consciousness were also analyzed. RESULTS: The mean VAS score was 5.1 ± 2 and 3.0 ± 2, which was lower in the intervention group (P value < 0.001). In terms of consciousness after biopsy, there was no difference between the two groups (P value = 0.358). There was no difference between the groups in terms of mean blood pressure and heart rate before and during the prostate biopsy. Finally, in terms of consciousness after the prostate biopsy, there was no difference between the current treatment and intervention groups. CONCLUSIONS: The combination of lidocaine gel and fentanyl with a dose of 50 µg has a significant effect on reducing the pain associated with prostate biopsy in comparison with lidocaine gel alone. The antinociceptive effect of the above regimens is not associated with hemodynamic changes and changes in patients' consciousness.

Comparison Effect of Promethazine/Dexamethasone and Metoclopramide /Dexamethasone on Postoperative Nausea and Vomiting after Laparascopic Gastric Placation: A Randomized Clinical Trial.

BACKGROUND: Laparoscopic gastric plication (LGP) is a technique in the restrictive category of bariatric procedures that reduces the gastric volume and increases intragastric pressure. Nausea and vomiting are the most common complications after this procedure. The goal of this research is to compare the combined effect of promethazine/dexamethasone versus Metoclopramide/ dexamethasone on the prevention of nausea and vomiting after LGP. METHODS: In recovery, the patients were divided into two groups, the Metoclopramide group which was given Metoclopramide 10 mg plus dexamethasone 4 mg/8 hours intravenous for 48 hours, and the promethazine group which was given promethazine 50 mg /12 hours, intramuscular for the first 24 hours and then promethazine 25 mg/12 hours for the next 24 hours plus dexamethasone 4 mg/8 hours intravenous for 48 hours. The frequency of nausea and vomiting, number of reflux episodes, frequency of epigastric fullness, and the duration of walking around q12 hours were recorded in the first 48 hours post-operation. RESULTS: Eighty patients were enrolled into the study. Promethazine group were found to significantly reduce the incidence of PONV in the first 24 hours compared with the other group (41% vs. 97.5%), relative risk = 0.042 [95% CI = 0.006, 0.299]. The mean numbers of epigastric fullness and severity of epigastria pain were lower in the promethazine group (P = 0.01) and the total opioid requirement was also reduced in promethazine group (32.1 ± 2.6 VS .68.5 ± 4.6 mg). However, the patients in the promethazine group were more sedated, which caused the duration of walking q12 hours in this group to decrease. CONCLUSIONS: In morbidly obese patients undergoing laparoscopic gastric plication, promethazine/dexametasone was more effective than Metoclopramide/dexametasone in preventing and reducing the incidence of nausea, epigastric fullness, and reflux. That combination was also more effective than Metoclopramide in reducing the severity of epigastric pain.

The effect of nephrostomy tract infiltration of ketamine on postoperative pain and peak expiratory flow rate in patients undergoing tubeless percutaneous nephrolithotomy: a prospective randomized clinical trial.

Ketamine, as a systemic and local analgesic, has been used to reduce postoperative pain in many studies. The present study was designed to assess the analgesic efficacy of nephrostomy tract infiltration of ketamine in postoperative pain after tubeless percutaneous nephrolithotomy (PCNL). Sixty-six patients with renal stone who were candidates for PCNL were randomized to two groups with 33 patients in each group. In group K, 20 mL saline solution containing 1.5 mg/kg ketamine was infiltrated into the nephrostomy tract and in group C, 20 mL saline solution was infiltrated into the nephrostomy tract at the end of surgery. The postoperative pain scores, sedation scores, time to first rescue analgesia, rescue analgesic requirement, peak expiratory flow rate (PEF), and hemodynamic parameters were compared between two groups. Sixty-six patients with a mean age of 45.29 ± 15 years and an age range of 18-60 years participated in this study. There was no significant difference in the demographic data and duration of surgery between the two groups. The mean VAS scores were significantly lower in the intervention group compared with the control group at the recovery, and 4 and 6 h postoperatively (p = 0.001). The mean time to first rescue analgesia in the postoperative period was significantly lower in the control group (64.5 ± 8.1 min) compared with the intervention group (122 ± 18.4 min). The trend of first opioid administration was significantly lower in the ketamine group p < 0.009. There was no significant differences in PEF between the two groups in the postoperative period (p = 0.622). In conclusion infiltration of ketamine into the nephrostomy tract provides superior analgesic and sedative effects in PCNL surgery without significant changes in PEF.

Comparison of Arterial Oxygenation Following Head-Down and Head-Up Laparoscopic Surgery.

BACKGROUND: Regarding the role of gas entry in abdomen and cardiorespiratory effects, the ability of anesthesiologists would be challenged in laparoscopic surgeries. Considering few studies in this area and the relevance of the subject, this study was performed to compare the arterial oxygen alterations before operation in comparison with after surgery between laparoscopic cholecystectomy and ovarian cystectomy. METHODS: In this prospective cohort, 70 consecutive women aged from 20 to 60 years who were candidate for laparoscopic cholecystectomy (n = 35) and ovarian cystectomy (n = 35) with reverse (20 degrees) and direct (30 degrees) Trendelenburg positions, respectively, with ASA class I or II were enrolled. After intubation and before operation, for the first time, the arterial blood gas from radial artery in supine position was obtained for laboratory assessment. Then, the second blood sample was collected from radial artery in supine position and sent to the lab to be assessed with the same device after 30 minutes from surgery termination. The measured variables from arterial blood gas were arterial partial pressure of oxygen (PaO2) and Oxygen saturation (SpO2) alterations. RESULTS: Total PaO2 was higher in the first measurement. The higher values of PaO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.060) and multivariate analysis (P = 0.654). Furthermore, higher values of SpO2 in cholecystectomy (upward) than in ovarian cystectomy (downward) were not significant in univariate (P = 0.412) and multivariate analysis (P = 0.984). CONCLUSIONS: In general, based on the results of this study, the values of PaO2 in cholecystectomy (upward) were not significantly higher than the values in cystectomy (downward) in laparoscopic surgeries when measured 30 minutes after surgery.

Combined Ketamine-Tramadol Subcutaneous Wound Infiltration for Multimodal Postoperative Analgesia: A Double-Blinded, Randomized Controlled Trial after Renal Surgery.

BACKGROUND: Pain is an important consideration after renal surgery. A multimodal approach to postoperative pain management could enhance analgesia by risking fewer side effects after surgery. OBJECTIVES: The aim of this study was to evaluate the clinical efficacy of the subcutaneous infiltration of ketamine and tramadol at the incision site to reduce postoperative pain. METHODS: Sixty-four patients between 18 and 80 years old who were scheduled for elective renal surgery were enrolled in a double-blind randomized controlled study. At the end of the surgery, patients were divided into four groups with 16 patients in each group: the saline group, who were treated with 10 mL of saline solution; the K group, who were treated with 1 mg/kg etamine in 10 mL of saline solution; the T group, who were treated with 1 mg/kg tramadol in 10 mL of saline solution; and the K/T group, who were treated with 0.5 mg/kg ketamine with 0.5 mg/kg tramadol in 10 mL of saline solution. In each group, the solution was infiltrated subcutaneously at the incision site. The postoperative pain scores and rescue analgesic consumption of the patients in each group were recorded for 24 hours and compared. The primary goal of the study was to compare the results of patients treated with a combined ketamine and tramadol subcutaneous wound infiltration, patients treated with a tramadol subcutaneous wound infiltration, and patients treated with a ketamine subcutaneous wound infiltration. RESULTS: Sixty-four patients were enrolled in the study. Pain intensity and cumulative meperidine consumption were significantly lower in the K/T group (27 mg; 95% confidence interval, 25.2 - 53.2) in comparison with the group that received a saline infusion during the first 24 hours after surgery (P < 0.001). The sedation score of the K, T, and K/T groups were significantly higher than the saline group (P < 0.001). CONCLUSIONS: The combined subcutaneous infiltration of ketamine and tramadol at the incision site produces better analgesia and an opioid-sparing effect during the first 24 hours when compared with the control group and the groups that received a subcutaneous infiltration of only ketamine or tramadol.

Multimodal Analgesia With Ketamine or Tramadol in Combination With Intravenous Paracetamol After Renal Surgery.

BACKGROUND: Opioids are generally the preferred analgesic agents during the early postoperative period. OBJECTIVES: The present study was designed to assess and compare the multimodal analgesic effects of ketamine and tramadol in combination with intravenous acetaminophen after renal surgery. PATIENTS AND METHODS: This randomized, double-blinded, clinical trial was conducted on 80 consecutive patients undergoing various types of kidney surgeries in Sina hospital in Tehran in 2014 - 2016. After extubation, the patients were randomly assigned to receive intravenous paracetamol (1 gr) plus tramadol (0.7 mg/kg) (PT group) or paracetamol (1 gr) plus ketamine (0.5 mg/kg) (PK group) within ten minutes. Pain severity was assessed by the visual analog scale (VAS), and the level of agitation was assessed by the Ramsey sedation scale (RSS). Morphine consumption was assessed within the first six hours after drug injection, and hemodynamic parameters were assessed at 5, 10, and 20 minutes after infusion, at the time of transfer from recovery to the ward, and also at one and six hours after transfer to the ward. RESULTS: Postoperative pain scores were significantly lower in the PK group than in the PT group during all study time points. The mean dose of morphine needed at recovery in the PK group was lower compared with the PT group (0.47 ± 0.94 mg versus 1.50 ± 1.35 mg/P = 0.001). The level of agitation based on the RSS score was significantly lower in the PK group than in the PT group at 10 and 20 minutes after drug administration. The total postoperative complication rate in the PK group was lower than in the PT group (20% versus 53.3%, P = 0.007). In this regard, catheter bladder discomfort was more frequent in the PT group than in the PK group (43.3% versus 3.3%, P < 0.001). CONCLUSIONS: The combination of intravenous paracetamol 1 gr and ketamine 0.5 mg/kg resulted in an overall reduction in pain scores, decreased postoperative analgesic requirements, and lower agitation score compared with intravenous paracetamol 1 gr and tramadol 0.7 mg/kg for patients undergoing renal surgery.

Skin Temperature Over the Carotid Artery, an Accurate Non-invasive Estimation of Near Core Temperature.

BACKGROUND: During anesthesia, continuous body temperature monitoring is essential, especially in children. Anesthesia can increase the risk of loss of body temperature by three to four times. Hypothermia in children results in increased morbidity and mortality. Since the measurement points of the core body temperature are not easily accessible, near core sites, like rectum, are used. OBJECTIVES: The purpose of this study was to measure skin temperature over the carotid artery and compare it with the rectum temperature, in order to propose a model for accurate estimation of near core body temperature. PATIENTS AND METHODS: Totally, 124 patients within the age range of 2 - 6 years, undergoing elective surgery, were selected. Temperature of rectum and skin over the carotid artery was measured. Then, the patients were randomly divided into two groups (each including 62 subjects), namely modeling (MG) and validation groups (VG). First, in the modeling group, the average temperature of the rectum and skin over the carotid artery were measured separately. The appropriate model was determined, according to the significance of the model's coefficients. The obtained model was used to predict the rectum temperature in the second group (VG group). Correlation of the predicted values with the real values (the measured rectum temperature) in the second group was investigated. Also, the difference in the average values of these two groups was examined in terms of significance. RESULTS: In the modeling group, the average rectum and carotid temperatures were 36.47 ± 0.54°C and 35.45 ± 0.62°C, respectively. The final model was obtained, as follows: Carotid temperature × 0.561 + 16.583 = Rectum temperature. The predicted value was calculated based on the regression model and then compared with the measured rectum value, which showed no significant difference (P = 0.361). CONCLUSIONS: The present study was the first research, in which rectum temperature was compared with that of skin over carotid artery, to find a safe location with easier access and higher accuracy for estimating near core body temperature. Results obtained in this study showed that, using a model, it is possible to evaluate near core body temperature in children, by measuring skin temperature over carotid artery.

An Assessment of Intubation Skill Training in Novice Anesthesiology Residents of Tehran University of Medical Sciences With the Use of Mannequins.

BACKGROUND: The goal of this study was to evaluate the impact of intubation skill training involving the use of mannequins on novice anesthesiology residents in a knowledge, attitudes, and practices designed study in which three different types of evaluation were implemented. METHODS: All first-year anesthesiology residents (24) of Sina Hospital, affiliated to the Tehran University of Medical Sciences, were invited to participate in an intubating skills training course. The program comprised two theoretical and three practical sessions, lasting a total of 16 hours over four days. Faculty assessment of residents' practices was carried out using the questionnaire results, measured using a Likert scale, as the primary outcome. An improvement in the theoretical knowledge of the novice anesthesiology residents (using the Likert scale) and their attitudes towards the educational course in general (via a multiple choice question examination), were also evaluated. RESULTS: The mean score following faculty assessment of the residents' practical skills was 4.6 out of 5.0 (92%) [standard deviation (SD) of 0.13]. The mean score with respect to the attitudes of the residents was 4.8 out of 5.0 (96%) (SD of 0.16). The overall mean theoretical score of the residents improved significantly upon completion of the training program (P = 0.001). CONCLUSIONS: Our results suggest that the personnel in the five participating faculties were highly satisfied with the practical performance of the residents, who were found to hold good attitudes towards the program as a whole.

Comparison of aPTT and CT Parameter of the ROTEM Test to Monitor Heparin Anti-Coagulation Effect in ICU Patients: an Observational Study.

Heparin is frequently used in different clinical settings to reduce the coagulating ability of the blood. Because of probable adverse effects owing to heparin therapy and regarding variability of patients' responses to heparin, which make it very unreliable, it seems prudent to monitor meticulously its effects on the human body. There are a lot of laboratory tests to watch its effects on the body for example; aPTT and ROTEM are the most widely used tests that are performed today. We aimed to compare the aPTT test results against changes of CT parameter of the ROTEM test due to heparin administration. This study was conducted on 45 critically ill patients who needed to receive heparin according to their clinical status. All patients received 550 to 1500 unit heparin per hour (on average 17.5 unit heparin per kilogram weight). While the patients were under infusion of heparin, two blood samples (5 ml) were taken from a newly established cubital vein, just five hours after commencement of heparin therapy. One sample was used for aPTT and the other one for ROTEM. The correlation between aPTT and the changes of CT parameter of the ROTEM with heparin dosage and infusion was the primary outcome. The correlation between heparin therapy and the changes of other parameters like MCF, CFT, and a number of platelets were the secondary outcome of the study. The only significant correlation was between changes of CT and aPTT (P=0.000). The other variables were not correlated. Changes of CT parameter of ROTEM test can be used for monitoring of reduced coagulability during heparin infusion instead of aPTT test.

The Comparison of Procalcitonin Guidance Administer Antibiotics with Empiric Antibiotic Therapy in Critically Ill Patients Admitted in Intensive Care Unit.

The empiric antibiotic therapy can result in antibiotic overuse, development of bacterial resistance and increasing costs in critically ill patients. The aim of the present study was to evaluate the effect of procalcitonin (PCT) guide treatment on antibiotic use and clinical outcomes of patients admitted to intensive care unit (ICU) with systemic inflammatory response syndrome (SIRS). A total of 60 patients were enrolled in this study and randomly divided into two groups, cases that underwent antibiotic treatment based on serum level of PCT as PCT group (n=30) and patients who undergoing antibiotic empiric therapy as control group (n=30). Our primary endpoint was the use of antibiotic treatment. Additional endpoints were changed in clinical status and early mortality. Antibiotics use was lower in PCT group compared to control group (P=0.03). Current data showed that difference in SOFA score from the first day to the second day after admitting patients in ICU did not significantly differ (P=0.88). Patients in PCT group had a significantly shorter median ICU stay, four days versus six days (P=0.01). However, hospital stay was not statistically significant different between two groups, 20 days versus 22 days (P=0.23). Early mortality was similar between two groups. PCT guidance administers antibiotics reduce antibiotics exposure and length of ICU stay, and we found no differences in clinical outcomes and early mortality rates between the two studied groups.

Intrarectal Lidocaine-Diltiazem-Meperidine Gel for Transrectal Ultrasound Guided Prostate Biopsy.

BACKGROUND: TRUS-guided needle biopsy of the prostate gland is the current standard method used for diagnosis of prostate cancer. Pain control during this procedure is through the use of i.v. sedation or local anaesthetic (LA), depending on clinician preference. OBJECTIVES: The aim of this study was to evaluate the effectiveness of intrarectal lidocaine, lidocaine-diltiazem and lidocaine-meperidine-diltiazem gel for anesthetizing transrectal ultrasound guided prostate biopsy. PATIENTS AND METHODS: In a randomized double-blind clinical trial, 100 consecutive patients were divided into three groups. The patients received one of the gels before transrectal ultrasound guided prostate needle biopsy: group A, intrarectal and perianal lidocaine, gel 1 g; group B, intrarectal lidocaine gel, 1 g, + perianal diltiazem, 1 g; group C, intrarectal lidocaine gel, 1 g, + meperidine, 25 mg, and perianal diltiazem, 1 g. Visual analog pain scale was used to estimate pain during probe insertion and biopsy. Heart rate and blood pressure during probe insertion and biopsy were recorded too. RESULTS: The mean of visual analog pain scale was 4.5 in group A, 3.5 in group B, and 2.0 in group C during probe insertion (P value = 0.01). The mean of visual analog pain scale was 5.1 in group A, 3.5 group B, and 2.5 in group C during biopsy (P value = 0.001). The groups were comparable for patients' age, weight, serum prostate-specific antigen (PSA), and prostate size (P > 0.05). No side effects of meperidine and lidocaine including drowsiness, dizziness, tinnitus and light-headedness or requiring assistance for activity were noted. CONCLUSIONS: Lidocaine-meperidine-diltiazem gel provides significantly better pain control than lidocaine-diltiazem gel and lidocaine gel alone during transrectal ultrasound guided prostate biopsy and probe insertion. This mixture gel is safe, easy to administer and well accepted by patients.

Effects of Ropivacaine on Postoperative Pain and Peak Expiratory Flow Rate in Patients Undergoing Percutaneous Nephrolithotomy.

BACKGROUND: Postoperative analgesic effects of ropivacaine have been demonstrated in various surgical procedures; however, its beneficial effect on postoperative pain relief and ability to breathe out air in urological surgeries, particularly in local interventions such as percutaneous nephrolithotomy (PCNL), has remained uncertain. OBJECTIVES: The aim of this study was to assess the efficacy of ropivacaine on postoperative pain severity and peak expiratory flow (PEF) in patients undergoing PCNL procedure. PATIENTS AND METHODS: This randomized double-blinded clinical trial was performed on 55 consecutive adult patients aged 15 to 60 years who underwent Tubeless PCNL surgery. The patients were randomly assigned to instill 30 mL of ropivacaine 0.2% or 30 mL of isotonic saline with the same protocol. The parameters of visual analogue scale (VAS) (for assessment of pain severity) and PEF (for assessment of ability to breathe out air) were measured 4 and 6 hours after completing the procedure. Moreover, the amounts of opioids or analgesics administered within 6 hours after the operation were recorded. RESULTS: We found no difference in the mean pain severity score between the case and control groups 4 hours (P = 0.332) and 6 hours (P = 0.830) after the operation. The mean PEF at baseline was similar in case and control groups (P = 0.738). Moreover, no difference was revealed in PEF index 4 hours (P = 0.398) and 6 hours (P = 0.335) after PCNL between the groups. The mean VAS scores 4 hours after the operation slightly decreased 2 hours later (P < 0.001) in the both groups. Moreover, in the both groups, a sudden decrease in PEF index was observed within 4 hours after the operation and increased with a mild gradient for the next 2 hours. No difference was found in the amount of postoperative analgesic used in the both groups. CONCLUSIONS: Instillation of ropivacaine 0.2% (30 mL) within tubeless PCNL surgery does not have a significant effect on postoperative pain relief and improvement of PEF within 6 hours after the operation.

Prophylactic administration of fibrinogen concentrate in perioperative period of total hip arthroplasty: a randomized clinical trial study.

According to limitations in blood product resources and to prevent unnecessary transfusions and afterwards complications in perioperative period of total hip arthroplasty, authors administered fibrinogen concentrate in a pilot randomized clinical trial to evaluate bleeding and need to blood transfusion in preoperative period. Thirty patients (3-75 years old) with ASA physical status class I or II and candidate for total hip arthroplasty consequently enrolled in this study and randomly assigned into two groups: taking fibrinogen concentrate and control. Two groups were similar in serum concentration of fibrinogen, hemoglobin, and platelet preoperatively. After induction of general anesthesia 30 mg/kg fibrinogen concentrate was administered in the fibrinogen group. Blood loss, need to blood transfusion and probable complications were compared between two groups. The mean operation time was 3.3 ± 0.8 hours in the fibrinogen group and 2.8 ± 0.6 hours in the placebo group, and this difference was statistically significant (P=0.04). There was a significant correlation between operation time and blood loss during surgery (P=0.002). The mean transfused blood products in the fibrinogen and control group was 0.8 ± 1.01 units and 1.06 ± 1.2 units respectively (P=0.53). The mean of perioperative blood loss was 976 ± 553 ml in the fibrinogen group and 1100 ± 350 ml in the control group, but this difference was not significant between two groups. By adjusting time factor for two groups, we identified that the patients in fibrinogen group had lower perioperative bleeding after adjusting time factor for two groups (P=0.046). None of the patients had complications related to fibrinogen concentrate administration. The prophylactic administration of fibrinogen concentrate was safe and effective in reducing bleeding in the perioperative period of total hip arthroplasty.

Is epidural dexamethasone effective in preventing postdural puncture headache?

BACKGROUND: Postdural puncture headache (PDPH) is one of the common complications of spinal anesthesia; it is observed in 1-40% of cases involving spinal anesthesia. It can cause considerable morbidity and 40% of cases may require invasive treatments such as epidural blood patch. With the exception of invasive treatments such as an epidural blood patch, current standard treatment modalities have not proved efficacious. There had been some research done that indicated successful prophylaxis and/or treatment of PDPH by administration of intravenous steroids. Based on those findings, we hypothesize that a direct injection of corticosteroids to the anesthesia puncture site could increase the amount of corticosteroid that accumulates in the puncture site, and will be more effective in decreasing dural inflammation and incidence of PDPH than that of parenteral steroids. We formulated our study to evaluate the effect of dexamethasone directly injected into spinal anesthesia puncture sites. METHODS: A total of 268 patients undergoing spinal anesthesia were randomly allocated into two groups; one group received a prophylactic epidural injection of dexamethasone (2 mL, 8 mg) and the other group received 2 mL of normal saline. The incidence and intensity of PDPH and puncture site backache were each measured at 24 hours, 72 hours, and 7 days after spinal anesthesia. The intensity of the headache was graded according to the meningeal headache index. RESULTS: The overall incidence of headache during the 7-day period was 5 patients (3.7%) in the control group and 11 patients (8.2%) in the study group, which is not statistically significant (X(2) = 2.393 and p = 0.122. The severity of headache also shows no statistical significance (2.2% in cases versus 6% in controls; z = 1.53, p = 0.126). The intensity of headache reported at the 24 hours (z = 0.698; p = 0.485), 72 hours (z = 0.849; p = 0.396), and 7 days (z = 0.008; p = 0.994) was not different. There also was no difference in the incidence of backache in the two groups. CONCLUSION: In contrast to other studies that showed the efficacy of intravenous dexamethasone in the prevention and treatment of PDPH, our study did not show any significant effect of prophylactic epidural injection of dexamethasone in prevention of PDPH. However regarding the low number of PDPH in routine cases, evaluation of this intervention in groups with a high incidence of PDPH by using of particulate steroids is recommended to confirm these preliminary findings.

Magnesium Can Decrease Postoperative Physiological Ileus and Postoperative Pain in Major non Laparoscopic Gastrointestinal Surgeries: A Randomized Controlled Trial.

BACKGROUND: Magnesium is an antagonist of (N-methyl D-Aspartate) NMDA receptor and its related canals, and may affect perceived pain. OBJECTIVES: The aim of this study was to evaluate the impact of intravenous magnesium on the hemodynamic parameters, analgesic consumption and ileus. PATIENTS AND METHODS: A randomized, double blind, placebo controlled study was performed. Thirty two patients of ASA I or II, scheduled for major gastrointestinal (GI) surgery, were divided into magnesium and control groups. Magnesium group received a bolus of 40 mg/kg of magnesium sulphate, followed by a continuous perfusion of 10 mg/kg/h for the intraoperative hours. Postoperative analgesia was ensured by Morphine patient-controlled analgesia (PCA). The patients were evaluated by Intraoperative hemodynamic parameters, the postoperative pain by numeral rating scale (NRS), and the total dose of intraoperative and postoperative analgesic consumption. Postoperative hemodynamic, respiratory parameters, physiological gastrointestinal obstruction (ileus), and side effects were also recorded. RESULTS: The study included 14 males and 18 females. Age range of patients was 17 to 55 years old. The average age in the magnesium group was 41.33 ± 10.06 years and45.13 ± 11.74 years in control group. Mean arterial pressure (MAP) of magnesium group decreased during the operation but increased in control group (P < 0.001), and systemic vascular resistance (SVR) of magnesium group decreased during the operation also (P < 0.02) but increased in control group. Postoperative cumulative Morphine consumption in magnesium group, was significantly in lower level (P = 0.026). For NRS, severe pain was significantly lower, in magnesium group, at all intervals of postoperative evaluations, but moderate and mild pain were not lower significantly. Duration of postoperative ileus was 2.3 ± 0.5 days in magnesium group, and 4.2 ± 0.6 days in control group (P = 0.01). CONCLUSIONS: Intravenous magnesium reduces postoperative ileus, postoperative severe pain and intra/post operative analgesic requirements in patients after major GI surgery. No side effects of magnesium in these doses were seen, so it seems to be beneficial along with routine general anesthesia in major GI surgeries.

The analgesic efficacy of preoperative oral Ibuprofen and acetaminophen in children undergoing adenotonsillectomy: a randomized clinical trial.

BACKGROUND: Adenotonsillectomy is one of the most common surgical procedures in children. Several complications and morbidities are common after nasal surgeries and the most common is pain. Several techniques have been employed to reduce the severity of postoperative pain. One of the preoperative techniques is pre-emptive analgesia through preventive central hypersensitization. This technique is performed by applying analgesic methods before the onset of nociceptive stimuli, consequently decreasing postoperative analgesics requirements. OBJECTIVES: Preoperative oral drug administration for pain analgesia is performed in several methods. The aim of this study was to compare the analgesic effects of preoperatively administration of oral acetaminophen and ibuprofen. PATIENTS AND METHODS: In a double-blinded, randomized placebo-controlled study, sixty 4-12 years old ASA I or II children scheduled for elective adenotonsillectomy, were assigned to receive either acetaminophen 15 mg/kg, ibuprofen 10 mg/kg or placebo 30 minutes before the operation. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), upon arrival to the post anesthetic care unit (PACU) and ward. Findings were analyzed by SPSS version 17 using variance analysis and Tukey's test. RESULTS: The average pain intensities were significantly lower in acetaminophen group based on the CHEOPS in both PACU and ward compared to ibuprofen or placebo groups; but there was no difference in pain intensity between the ibuprofen and placebo groups. Pain intensity in PACU in Acetaminophen group was 7.05 ± 0.64 vs. 8.38 ± 1.20 in placebo group and 8.14 ± 0.85 in ibuprofen group, pain intensity in ward in the acetaminophen group was 6.0.87 ± 0.85in the acetaminophen group, vs. 8.04 ± 1.02 in placebo group, and 7.78 ± 0.78 in ibuprofen group. CONCLUSIONS: This study showed that administration of oral acetaminophen 30 minutes preoperatively, resulted in significantly lower pain intensity in children undergoing adenotonsillectomy in PACU and ward, compared to ibuprofen and placebo.

Postoperative sore throat after laryngoscopy with macintosh or glide scope video laryngoscope blade in normal airway patients.

BACKGROUND: The Glide Scope videolaryngoscope provides a suitable view for intubation, with less force required. OBJECTIVES: The present study was conducted, to compare postoperative sore throat and hoarseness after laryngoscopy and intubation, by Macintosh blade or Glide Scope video laryngoscope in normal airway patients. PATIENTS AND METHODS: Three hundred patients were randomly allocated into two groups of 150: Macintosh blade laryngoscope or Glide Scope video laryngoscope. The patients were evaluated for 48 hours for sore throat and hoarseness by an interview. RESULTS: The incidence and severity of sore throat in the Glide Scope group, at 6, 24 and 48 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. In addition, the incidence of hoarseness in the Glide Scope group, at 6 and 24 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. The incidence and severity of sore throat in men, at 6 and 24 hours after the operation, were significantly lower than in the women. CONCLUSIONS: The incidence and severity of sore throat and hoarseness after tracheal intubation by Glide Scope were lower than in the Macintosh laryngoscope. The incidence and severity of sore throat were increased by intubation and longer operation times.