Scalp Nerve Block for Enhanced Pain Control and Analgesic Optimization in Elective Craniotomy: A Randomized Controlled Trial with Analgesia Nociception Index Monitoring.

BACKGROUND: In patients who are candidates for craniotomy, scalp nerve blocks have been shown to be effective in relieving pain intensity as well as postoperative hemodynamic stability after surgery, but the results have been inconsistent. We aimed to assess the effect of scalp block on pain control, intraoperative drug use under Analgesia Nociception Index (ANI) monitoring, and postoperative pain in patients who were candidates for elective craniotomy. METHODS: In this randomized, single-blinded clinical trial study, candidates for craniotomy were randomly (using the block randomization method) divided into 2 groups before entering the operating room. The first group received a scalp block with bupivacaine (intervention), and the second group did not receive a scalp block (control) besides the routine anesthetic procedure in these patients. ANI, hemodynamic parameters, and the amounts of received remifentanil were conducted and compared. RESULTS: Patients under scalp block received less dosage of fentanyl than the nonscalp block group (mean = 57.14 ± 15.59 mcg vs. 250.00 ± 65.04 mcg, respectively). Similarly, the dose of remifentanil required in the scalp block group was less (mean = 3.04 ± 1.95 mg and 5.54 ± 2.57 mg, respectively). No difference was observed in hemodynamic parameters such as blood pressure and heart rate (before, during, and after surgery). However, the group receiving scalp block had higher ANI means than the control group. CONCLUSIONS: Scalp nerve block has an effective role in pain control (increasing ANI), consequently reducing the need for analgesic drugs such as fentanyl and remifentanil following craniotomy without changing the hemodynamic condition.

The Impact of Heparin Therapy in Deceased Donors on Early Graft Survival for Kidney and Liver Recipients: A Clinical Trial Study.

BACKGROUND: Significant hemodynamic, hormonal, and metabolic impairment of a brain-dead organ donor is often associated with the deterioration of graft viability. This study aimed to compare the effect of heparin therapy as a therapeutic dose after brain death confirmation on early graft survival in kidney and liver recipients. METHOD AND MATERIALS: The deceased donors were sorted into two groups based on their D-dimer level. After confirming brain death, one group was given a heparin injection (case group), while the other group did not receive any heparin (control group). A total of 71 brain death donors and matched kidney and liver transplants were included in the case group. A total of 43 brain death donors and matched kidney and liver transplants were included in the control group. A total of 5000 units of heparin were administered every 6 hours to the deceased donor case group. RESULTS: The mean age of the case and control groups were 36.27 ± 16.13 and 36.15 ± 18.45, respectively. An independent t test showed that there were no differences between the number of procured organs in both groups (p = 0.29). There was no significant difference between the graft survival rate and the doses of heparin injection to the liver recipients (p = 0.06). However, a significant difference was revealed between the graft survival rate and the dose of heparin injection (p = 0.004) in kidney recipients. CONCLUSIONS: The data suggest that administering low therapeutic doses of heparin to donors before organ donation may potentially prevent thrombosis and provide a protective benefit. We showed that heparin therapy had no significant effect on the number of donated organs and graft survival.

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.

Application of Awake Craniotomy and Intraoperative Brain Mapping for Surgical Resection of Insular Gliomas of the Dominant Hemisphere.

BACKGROUND: Radical resection of dominant insular gliomas is difficult because of their close vicinity with internal capsule, basal ganglia, and speech centers. Brain mapping techniques can be used to maximize the extent of tumor removal and to minimize postoperative morbidities by precise localization of eloquent cortical and subcortical areas. METHODS: Patients with newly diagnosed gliomas of dominant insula were enrolled. The exclusion criteria were severe cognitive disturbances, communication difficulty, age greater than 75 years, severe obesity, difficult airways for intubation and severe cardiopulmonary diseases. All were evaluated preoperatively with contrast-enhanced brain magnetic resonance imaging (MRI), functional brain MRI, and diffusion tensor tractography of language and motor systems. All underwent awake craniotomy with the same anesthesiology protocol. Intraoperative monitoring included continuous motor-evoked potential, electromyography, electrocorticography, direct electrical stimulation of cortex, and subcortical tracts. The patients were followed with serial neurologic examination and imaging. RESULTS: Ten patients were enrolled (4 men, 6 women) with a mean age of 43.6 years. Seven patients suffered from low-grade glioma, and 3 patients had high-grade glioma. The most common clinical presentation was seizure followed by speech disturbance, hemiparesis, and memory loss. Extent of tumor resection ranged from 73% to 100%. No mortality or new major postoperative neurologic deficit was encountered. Seizure control improved in three fourths of patients with medical refractory epilepsy. In one patient with speech disorder at presentation, the speech problem became worse after surgery. CONCLUSION: Brain mapping during awake craniotomy helps to maximize extent of tumor resection while preserving neurologic function in patients with dominant insular lobe glioma.

Effect of magnesium on functional outcome and paraclinical parameters of patients undergoing supratentorial craniotomy for brain tumors: a randomized controlled trial.

BACKGROUND: Several studies have demonstrated that magnesium (Mg) plays an important role in the prevention and treatment of central nervous system (CNS) insults. In this study, we tested the effect of intravenous magnesium sulfate (MgSO4) on the outcome of patients with brain tumors who underwent craniotomy. The outcome was defined clinically as the Barthel index score and paraclinically as blood levels of NSE (neuron-specific enloase) and S100Β protein. METHODS: Sixty patients were randomly divided into two groups of 30 patients: the treatment and control groups. In the treatment group, 5 g of MgSO4 in normal saline was infused in 6 h 2 days before surgery, and the same dosage was repeated the day before and during surgery. The control group received placebo. Serum S100Β and NSE concentrations were measured at baseline before administration of magnesium, before surgery, and on the 2nd postoperative day. The Barthel index score was evaluated and registered before surgery, 3, and 6 months after the operation. RESULTS: The study results showed a significant change in S100Β protein levels before and after surgery (p < 0.05), but we could not find similar results for NSE protein and the Barthel index score. There was a correlation between NSE protein and the Barthel index. CONCLUSIONS: The results of this study revealed that administration of intravenous MgSO4 before and during surgery is safe and effective in reducing S100B protein levels in patients undergoing supratentorial craniotomy for brain tumors. Further studies to elucidate the pathophysiology of brain injuries and role of magnesium are warranted.

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.

Effects of intra-operative ketamine administration on postoperative catheter-related bladder discomfort: a double-blind clinical trial.

PURPOSE: Urinary catheterization during surgery frequently leads to unfavorable signs and symptoms (ie urgency, discomfort, frequency) during recovery. These signs and symptoms are collectively called catheter-related bladder discomfort (CRBD). We hypothesized that preemptive IV ketamine administration prior to intra-operative catheterization would reduce the incidence of CRBD in the postoperative period when compared to placebo. METHODS: The study consisted of 114 adult patients undergoing elective nephrectomy. They were randomized to 2 equal groups of 57 subjects. In the intervention group, IV ketamine (0.5 mg/kg) was administered directly after induction of anesthesia, but before urinary catheterization. The control group received an injection of 2 mL of normal saline. The study evaluated the incidence and severity of CRBD at 0, 1, 2, and 6 hours after commencement of the recovery period. The study also compared the incidence of postoperative nausea and vomiting, hallucinations, sedation, and respiratory depression in the 2 groups. RESULTS: At the 0- and 1-hour evaluations, the incidence and severity of CRBD were lower in the intervention group; however, at the 2- and 6-hour evaluations, there were no significant differences in incidence and severity of CRBD between the 2 groups. A decreased incidence of postoperative nausea and vomiting (PONV) was observed at 2- and 6-hour visits in the intervention group. Also, a higher occurrence of sedation was seen at the 0-hour checkup in the intervention group. CONCLUSION: Preemptive administration of IV ketamine (0.5 mg/kg) can reduce incidence and severity of CRBD in the early postoperative period.

Evaluation of the anti-inflammatory effects of peri-operative infusion of magnesium sulfate on the microsurgical procedures for intracranial tumors.

BACKGROUND: The anti-inflammatory properties of magnesium sulfate have never been discussed in brain tumor surgeries. OBJECTIVES: This study is aimed to find anti-inflammatory aspects of high dose magnesium sulfate infusion during perioperative period of neurosurgical patients through checking the serial C-reactive protein (CRP) blood levels as a biomarker of inflammation. PATIENTS AND METHODS: Sixty patients who were candidate for elective craniotomy were enrolled randomly into two equal groups to receive either magnesium sulfate or normal saline during their perioperative period. Infusion of magnesium was performed three times during the study and a summation of 15 grams was administered: 1- two days before surgery, 2- one day before surgery, 3- from the beginning of surgery (five grams was infused within six hours in each session). Serum level of CRP was checked just before commencement of magnesium infusion and on the first and second day after surgery as primary outcome. Hemodynamic parameters, total propofol requirement and total blood loss were recorded as well. RESULTS: No significant difference was found between groups in terms of serum CRP levels. The mean arterial blood pressure, heart rate, blood loss and total anesthetic requirement were significantly lower in magnesium group in comparison to the control group. CONCLUSIONS: We did not find conclusive evidence for anti-inflammatory effects of magnesium in craniotomy for microsurgery of intracranial tumors using CRP level changes. However, high dose magnesium might be suggested as a safe anesthetic adjuvant in neurosurgery.

Conscious Sedation and Analgesia in Colonoscopy: Ketamine/Propofol Combination has Superior Patient Satisfaction Versus Fentanyl/Propofol.

BACKGROUND: Colonoscopy is performed without preparing sedation in many countries. However, according to the current literature patients are more satisfied when appropriate sedation is prepared for them. OBJECTIVES: We hypothesize that propofol-ketamine may prepare more patient satisfaction compared to propofol-fentanyl combination. PATIENTS AND METHODS: Sixty adult patients older than 18 with ASA physical status of I, II or III were enrolled in the present study after providing the informed consent. They were prospectively randomized into two equal groups: 1- Group PF: was scheduled to receive IV bolus dose of fentanyl 1µg/kg and propofol 0.5mg/kg. 2- Group PK: was scheduled to receive IV bolus dose of ketamine 0.5mg/kg and propofol 0.5mg/kg. As a primary goal, patient's satisfaction was assessed by the use a Likert five-item scoring system in the recovery. Comparisons of hemodynamic parameters (mean heart rate, mean systolic blood pressure, mean diastolic blood pressure), mean Spo2 values during the procedure and side effects such as nausea, vomiting, and psychological reactions during the recovery period were our secondary goals. Level of sedation during the colonoscopy was assessed with the Observer's Assessment of Alertness/Sedation score (OAA/S). RESULTS: Mean satisfaction scores in the group PK were significantly higher than the group PF (P = 0.005) while the level of sedation during the procedure was similar (P = 0.17). Hemodynamic parameters and SpO2 values were not significantly different (P > 0.05). Incidence of nausea and vomiting was the same in both groups. CONCLUSIONS: IV bolus injection of propofol-ketamine can lead to more patients' satisfaction than the other protocols during colonoscopy.

Effect of dexamethasone on the frequency of postdural puncture headache after spinal anesthesia for cesarean section: a double-blind randomized clinical trial.

In this study, we evaluated the effect of dexamethasone used as a prophylaxis for nausea and vomiting on the incidence of postdural puncture headache (PDPH) in pregnant women receiving spinal anesthesia for cesarean section. In a prospective, randomized, double-blind, placebo-controlled study, 372 women under spinal anesthesia received 8 mg of dexamethasone or placebo intravenously just after the umbilical cord was clamped. The rate of PDPH and correlated risk factors were evaluated. The prevalence of nausea and vomiting in the dexamethasone and placebo groups was 54.4 and 51.7%, respectively. There was no statistically meaningful difference between the results (P value = 0.673). The overall incidence rate of PDPH was 10.8%, with 28 cases from the dexamethasone group compared with 11 subjects from the placebo group (P value = 0.006). This effect was most prominent on the first day (P value = 0.046) and disappeared on the second day after spinal anesthesia (P value = 0.678). Prophylactic treatment with 8 mg of dexamethasone not only increases the severity and incidence of PDPH, but is also ineffective in decreasing the prevalence of intra-operative nausea and vomiting during cesarean section. The treatment is a significant risk factor for the development of PDPH.

Metformin treatment in hyperglycemic critically ill patients: another challenge on the control of adverse outcomes.

New-onset hyperglycemia in patients admitted to intensive care units increases the risk of morbidity and mortality. Insulin resistance is frequently seen in the treatment of stress-induced hyperglycemia. Metformin, an oral anti-hyperglycemic agent, may introduce a new treatment protocol in critically ill patients with insulin-resistance hyperglycemia. Fifty-one non-diabetic traumatized patients with blood sugar (BS) levels more than 130 mg/dLwere introducedto three days of treatment with intensive insulin (50 IU) or metformin (1000 mg, twice daily) therapy. Clinical evaluationsincluded acute physiological and chronic health evaluation (APACHE II) and Glasgow Coma Scale (GCS). Experimental tests included BS level, mean arterial pressure (MAP), pH, HCO3, and lactate. Eight patients were excluded and 21 of remained patients treated with insulin and 23 with metformin. There was no significant difference in terms of the evaluated factors between the two groups at the time of admission. Although desirable BS level (BS < 130 mg/dL) was reached by three days of metformin treatment (p < 0.01),there was no significant difference in BS, MAP, pH and HCO3of insulin treated groupin comparison with metformin treated patients. The findings weresimilar for APACHE II and GCS as well. Although obvious studies are required, these findings may lead to effective therapies against stress-induced hyperglycemia.

Microalbuminuria in hyperglycemic critically ill patients treated with insulin or metformin.

Microalbuminuria is thought to reflect the severity of inflammation-induced systemic vascular permeability. The present study investigated the effect of early administration of metformin or insulin on microalbuminuria in traumatized critically ill patients. Between April 2006 and October 2007, thirty-one non-diabetics traumatized patients with systemic inflammatory response syndrome (SIRS) and blood sugar (BS) >130 mg/dL at admission to ICU (Intensive Care Unit) of Sina Hospital (Tehran, Iran), were randomly assigned to receive intensive intravenous insulin (50 IU) or peroral metformin (1000 mg, twice daily) for three days. Microalbuminuria to creatinine ratio (MACR) and BS were measured during the three-day period. Eight patients were excluded during the study and 23 remained for the evaluations. There was no statistically significant difference between two groups with respect to MACR levels at admission and during the three-day period of treatment except for the time 6 and 48 h, that MACR was higher in insulin group than that in metformin group (p < 0.05). Metformin but not insulin reduced BS level significantly (p < 0.05). There was a significant positive correlation between BS and MACR in both insulin (p < 0.05; R(2) = 0.131) and metformin (p < 0.05; R(2) = 0.127) groups. Glasgow Coma Scale (GCS) and APACHE II had significant correlation with MACR in metformin treated patients (p < 0.05; R(2) = 0.134 and p < 0.05; R(2) = 0.149) while in insulin treated patients only the values of GCS had significant correlation with MACR values (p < 0.05, R(2) = 0.124). In conclusion, it was found that peroral metformin may be used instead of intravenous insulin in traumatized critically ill patients for lowering BS and MACR. A predictive role for MACR may be suggested although further studies with larger sample size of patients is required.