Dexmedetomidine or Fentanyl, Which One Is Better as an Adjunct Drug in Epidural Anesthesia and Causes More Postoperative Pain Reduction? A Comparative Study, a Randomized Clinical Trial.

Objectives: This study compared dexmedetomidine to fentanyl as an adjunct to ropivacaine for epidural anesthesia in patients undergoing femoral neck fracture surgery. Methods: A total of 56 patients in two different groups with dexmedetomidine and fentanyl underwent the epidural anesthesia method by ropivacaine. This study compared the onset and duration of sensory block, duration of motor block, visual analog scale (VAS) analgesia, and sedation score. The VAS and hemodynamics (e.g., heart rate and mean arterial pressure) were measured every 5 to 15 minutes, then every 15 minutes to the end of the surgery, and then in the 1st, 2nd, 4th, 6th, 12th, and 24th hours after surgery. Results: In the fentanyl group, the onset time of the sensory block was longer (P < 0.001), and the duration of the block was shorter than in the dexmedetomidine group (P = 0.045). In the fentanyl group, the onset time of motor block was longer than in the dexmedetomidine group (P < 0.001). The mean highest VAS score for each patient in the dexmedetomidine group was 4.9 ± 0.6, compared to the fentanyl group (5.8 ± 0.9), with a significant difference between the two groups (P < 0.001). The sedation score was higher from the 30th minute (P = 0.01) to the 120th minute (P = 0.04) in the patients of the dexmedetomidine group than in the fentanyl group. Side effects, such as dry mouth, hypotension, and bradycardia, were more common in the dexmedetomidine group, and nausea and vomiting were more common in the fentanyl group; however, there were no differences between the groups. There was no respiratory depression in both groups. Conclusions: This study presented that dexmedetomidine as an adjuvant in epidural anesthesia for orthopedic femoral fracture surgery shortens the onset time of sensory and motor block, increases analgesia length, and prolongs anesthesia. Sedation with dexmedetomidine is better than fentanyl, with fewer side effects, and more effective as preemptive analgesia.

Effect of N-Acetylcysteine on the treatment of acute respiratory distress syndrome in mechanically ventilated patients admitted to the intensive care unit.

Background: N-acetylcysteine (NAC) is an antioxidant derived from the amino acid cysteine and is one of the drugs used in the treatment of respiratory diseases. The aim of this study was to investigate the effect of NAC on the treatment of acute respiratory distress syndrome in mechanically ventilated patients admitted to the intensive care unit. Methods: This study was a randomized clinical trial. Patients under mechanical ventilation admitted to the intensive care unit were examined. Patients in the intervention group received daily 150 mg/kg of NAC on the first day of admission and then 50 mg/kg up to the fourth day of admission. Patients in the control group received routine care. The vital signs, level of consciousness, and other important variables were recorded. Data were analyzed using statistical tests and SPSS software version 24. Results: There was no significant difference between MAP, heart rate, respiratory rate, O2Sat, APACHE II score, and pulmonary capacity of the patients in the two groups on the first, second, third and fourth days after the intervention (p>0.05 ). There was no significant difference between the level of consciousness (according to GCS criteria), respiratory index (PAO2/FIO2) and PEEP of patients in the two study groups within 1 to 2 days after the intervention (p>0.05). There was a significant difference between the level of consciousness (based on GCS criteria), respiratory index (PAO2/FIO2) and PEEP of patients in the two study groups within 3 to 4 days after the intervention (p<0.05). There was no significant difference between the duration of hospitalization in the ICU, the time required for mechanical ventilation and the mortality rate of the patients in the two groups (p>0.05). Conclusion: It seems that N-acetylcysteine has a positive effect on the treatment of acute respiratory distress syndrome in mechanically ventilated patients admitted to the intensive care unit.

Effect of Nebulized Heparin on Weaning off Intubated Patients with Acute Respiratory Distress Syndrome (ARDS) Admitted to Intensive Care Unit (ICU): A Randomized Clinical Trial.

BACKGROUND: Acute respiratory distress syndrome (ARDS) treatment is based on supportive care such as mechanical ventilation, prophylaxis of stress ulcer, prophylaxis of deep vein thrombosis (DVT), nutritional support, and treatment of underlying disease. OBJECTIVES: We aimed to investigate the effects of nebulized heparin on weaning off intubated ARDS patients admitted to the intensive care unit (ICU). METHODS: In this double-blind clinical trial study, 60 patients with ARDS receiving routine care according to the ARDS protocol were randomly assigned into two groups: intervention group (receiving nebulized heparin 5000 u/BD for one week) and control group (receiving nebulized sterile water 2 cc/BD for one week). The respiratory index (PaO2/FiO2), pulmonary shunt percentage (measured by ABG), tidal volume, minute ventilation, admission duration in the ICU, and days of mechanical ventilation required were recorded for each patient for one week. RESULTS: There was no significant difference in demographic data between the two groups. Inhaled heparin in patients with ARDS could significantly increase the respiratory index (PaO2/FiO2) and decrease pulmonary shunt percentage, minute ventilation, and tidal volume. It also significantly reduced the number of admission days in the ICU and the need for mechanical ventilation. CONCLUSIONS: The result of the present study showed that inhaled heparin in intubated ARDS patients admitted to the ICU improved respiratory and pulmonary status and reduced the need for mechanical ventilation and admission days in the ICU. Nebulizing heparin, as an anti-inflammatory and anti-coagulant agent, is an effective and safe medication for ARDS patients on mechanical ventilation.

Comparison of Sedation with Dexmedetomidine Alfentanil Versus Ketamine-Alfentanil in Patients Undergoing Closed Reduction of Nasal Fractures.

OBJECTIVES: To compare the sedative effects of dexmedetomidine alfentanil versus ketamine-alfentanil in patients undergoing closed reduction of nasal fractures on the basis of intraoperative hemodynamic changes, satisfaction of patients and surgeons, and the adverse effects. METHODS: Sixty patients with ASA class 1 or 2 were randomized to either of two groups, a dexmedetomidine alfentanil group (DA group; n = 30) or a ketamine-alfentanil group (KA group; n = 30). Hemodynamic parameters, oxygenation status, adverse events, the satisfaction of patients and surgeons, and postoperative pain scores by visual analog scale (VAS) were recorded at specific time intervals during the trial. RESULTS: Systolic blood pressure was significantly lower in the DA group than in the KA group from T1 min to T15 min. The duration of the recovery ward stay was longer in the DA group; however, two groups were similar in terms of total anesthesia time and awakening time. Likewise, two groups were similar in terms of the patient and surgeon's satisfaction, pain scores, and the occurrence of adverse effects. CONCLUSIONS: Both sedation methods were safely performed, and dexmedetomidine-alfentanil is as effective as ketamine-alfentanil in patients undergoing short-term operations such as nasal fracture corrections.

Comparing the Effect of Bupivacaine and Ropivacaine in Cesarean Delivery with Spinal Anesthesia.

BACKGROUND: Spinal anesthesia is the most common technique used for cesarean delivery due to some advantages compared to regional anesthesia. It is easily performed and provides a rapid onset of block. Though bupivacaine is a generally used long-acting amide type local anesthetic drug for spinal anesthesia, ropivacaine may sometimes be selected. OBJECTIVES: This prospective, randomized, double-blinded study was aimed at comparing clinical efficacy and safety between ropivacaine and bupivacaine during cesarean section. METHODS: After getting ethical committee approval and written informed consent, 65 women who referred to Imam Khomeini Hospital of Ahvaz, Iran in 2018 were chosen for elective cesarean delivery under spinal anesthesia. They were randomly allocated to receive either ropivacaine 1% (n = 33) or bupivacaine 0.5% (n = 32). Afterwards, the differences in the anesthetic efficacy, vital signs, and hemodynamics of participants between the two groups were recorded. RESULTS: Duration of sensory block was shorter in the ropivacaine group than bupivacaine group (132.5 ± 21.6 min vs. 175.8 ± 26.2 min; P < 0.001). Ropivacaine also produced a shorter duration of motor blockade than bupivacaine (124.8 ± 20.2 min vs. 168.2 ± 21.7 min; P < 0.001). There is no difference between the two groups in terms of systolic and diastolic blood pressure, but the heart rate of patients in the bupivacaine group is significantly higher than the ropivacaine group. CONCLUSIONS: The results suggest that ropivacaine and bupivacaine are two efficient drugs in anesthesia in the cesarean section, ropivacaine is a better choice due to little influence on the hemodynamics and shorter duration of sensory block and motor block which are useful for the recovery and also safe to the patients.

Comparison of Dexmedetomidine and Morphine as Adjuvants to Bupivacaine for Epidural Anesthesia in Leg Fracture Surgery: A Randomized Clinical Trial.

BACKGROUND: Epidural block approach and drugs are common options for improving the sensory and motor block duration and postoperative pain management. OBJECTIVES: The study aimed to compare the analgesic effects of dexmedetomidine and morphine as adjuvants to bupivacaine for epidural anesthesia in leg fracture surgery. METHODS: This prospective clinical trial was conducted on patients (n = 80, age range: 18 - 60 years) categorized as ASA class I or II. After a clinical examination, the patients were allocated to receive either lumbar epidural bupivacaine + morphine (BM) (12 mL bupivacaine 0.5% + morphine 2 mg) or bupivacaine + dexmedetomidine (BD) (12 mL bupivacaine 0.5% + dexmedetomidine 1 µg/kg). After drug administration, the sensory block level was assessed at 2-min intervals using the Cold Swab method until it reached the T12 level. At the T12 level of sensory block, the surgery began when motor block reached grade 3 of the modified Bromage scale. RESULTS: The BD group had a significantly shorter time to reach the sensory and motor block than the BM group (P < 0.001). The duration of sensory and motor block was significantly longer in the group BD than in the BM group (P < 0.001). Moreover, the BD group showed lower VAS scores (P < 0.0001) and longer time to first analgesia demand than the BM group. CONCLUSIONS: Combined bupivacaine + dexmedetomidine prolongs the sensory and motor block duration and controls postoperative pain more effectively, indicating that it is an appropriate combination for epidural anesthesia.

Comparison of the Ketamine-Lidocaine and Fentanyl-Lidocaine in Postoperative Analgesia in Axillary Block in Upper Limb Fractures By Ultrasound Guidance.

BACKGROUND: Regional anesthesia provides safe anesthesia for upper extremity surgery. Axillary plexus block approach for hand and forearm surgery is commonly used. The use of adjuvants in combination with local anesthetics for peripheral nerve blocks enhances the quality and duration of anesthesia and postoperative analgesia. METHODS: This double-blind clinical trial was performed on 60 patients who were candidates for the surgery of upper extremity fractures with ASA I and II classes. The patients were randomly divided into two equal groups (n = 30). The intervention group 1 received 4 mg/kg lidocaine 1% and 50 µg fentanyl and the intervention group 2 received 4 mg/kg lidocaine 1% and 30 mg ketamine during the axillary block. After the necessary monitoring, a pinprick test was performed to evaluate sensory block, and a three-point scale test for the motor block was performed for median, ulnar, radial and musculocutaneous nerves. The duration of postoperative analgesia, the time of the first request for a painkiller, and the amount of opioid received were compared in the two groups. RESULTS: Onset of sensory and motor block was shorter in the fentanyl group but did not differ significantly. The sensory and motor block length was slightly higher in the fentanyl group, but no significant difference was observed. The severity of pain (VAS) and the mean of received opioid (pethidine) were significantly lower in the fentanyl group 24 hours after the surgery (P < 0.0001). The duration of postoperative analgesia and the time of the first request for painkiller were longer in the fentanyl group, but there was no significant difference. CONCLUSIONS: The severity of pain and analgesic intake in the fentanyl group decreased significantly. Therefore, fentanyl is a better drug than ketamine for using as an adjuvant in the axillary block.

The Effects of Pre-Spinal Anesthesia Administration of Crystalloid and Colloid Solutions on Hypotension in Elective Cesarean Section.

BACKGROUND: Spinal anesthesia is an appropriate alternative for general anesthesia in many operations, particularly in cesarean section. However, the induced hypotension is the main drawback of this method. Therefore, the current study aimed at comparing the effects of crystalloid and colloid solutions used as the preload on the post-spinal hypotension and its complications in females who are candidate for elective cesarean section. METHODS: The current randomized, controlled, double-blind study was conducted on the female candidate of elective cesarean section (n = 96; age range: 20 to 40 years). The patients were in their 37 to 42 weeks of gestational age during the experiments. The systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) variation, amount of injected ephedrine during surgery, Apgar score at birth, total solution infused after spinal anesthesia, urine output, nausea, and vomiting were comparatively assessed between the two groups. RESULTS: The percentages of reduction in SBP and DBP variables in the crystalloid solution were higher than those of the colloid group and the differences were statistically significant (P = 0.042 and P = 0.008, respectively). Average percentage of HR changes was more significant in the crystalloid than the colloid group (P = 0.032). In contrary, administration of the two types of solutions did not result in significant differences in the Apgar scores. The prevalence of nausea and vomiting in the colloid group subjects was lower than those of the crystalloid solution group; however, the differences were not significant. CONCLUSIONS: The current study findings recommend colloid solution to prevent hemodynamic instability after spinal anesthesia. However, the costs and availability of the solution and recommendation of anesthesiologist should be considered. Conduction of further clinical trials with larger sample sizes is recommended.

The Effect of Adding Dexmedetomidine as an Adjuvant to Lidocaine in Forearm Fracture Surgeries by Supraclavicular Block Procedure Under Ultrasound-Guided.

BACKGROUND: To improve the brachial plexus block (BPB) performance, different compounds have been used as adjuvants to local analgesics. OBJECTIVES: The aim of the present study was to investigate the effects of adding DEX to lidocaine on effectiveness of nerve block, and postoperative pain in forearm fracture surgery by supraclavicular BPB undergoing ultrasound-guided. METHODS: This was a double-blinded randomized clinical trial conducted on 72 patients with ASA classes I and II, which were candidates for forearm fracture surgery. In group A, patients received 3 mg/kg of lidocaine 2%. In group B, patients received 3 mg/kg of lidocaine 2% and DEX (1 µg/kg). The ultrasound-guided supraclavicular BPB was performed in all patients. The onset of sensory and motor blocks were evaluated with pin prick test and modified Bromage scale, respectively. The sensory and motor block moment was recorded as the onset of the block. The first analgesic request time, total consumed analgesic, adverse effect, and hemodynamic parameters of patients were recorded. A visual analog scale (VAS) was used for recording the severity of pain. RESULTS: The two groups showed no significant difference in the demographic variables. The onset of sensory and motor block in the DEX groups was shorter. The duration of sensory and motor block, and analgesic request was significantly longer than the control groups. Total analgesic consumption 24 hours after surgery in the DEX groups was significantly lower. Moreover, hemodynamic status of patients in both groups was stable and no significant difference was observed between groups. This study showed that DEX, as an adjuvant to lidocaine, improve the characteristics of supraclavicular BPB and decrease the postoperative pain.

Analgesic effect of low dose subcutaneous ketamine administration before and after cesarean section.

BACKGROUND: Pain is considered as an importantissue after cesarean section. Multimodal approach to post cesarean pain management may not only enhance analgesia but also reduce side effects after the surgery. OBJECTIVES: This study was aimed to evaluate the clinical efficacy of subcutaneous injection of low dose ketamine at the incision site to reduce cesarean section pain. PATIENTS AND METHODS: Sixty patients, aged between 18 and 25 years old, scheduled for elective cesarean section, were enrolled to this double-blind randomized controlled trial study. Patients were divided into three groups of 20 patients each group one (k-pre) received 0.5 mg/kg ketamine before skin incision and normal saline after skin closure, group two (k-post) received normal saline before skin incision and 0.5 mg/kg ketamine after skin closure and group three (C) received normal saline before skin incision and after skin closure; subcutaneously at the incision site. The first analgesic request, the amount of analgesic and the pain intensity were evaluated for 24 hours. RESULTS: The first time analgesic requested was longer and the amount of analgesic used during the first 24 hours was significantly lower in groups K-pre and K-post compared with group C (P < 0.05). Pain intensity was significantly lower at 2, 4, 6 and 12 hours in groups K-pre and K-post compared with group C (P < 0.05). Nevertheless, pain intensity was not significantly different at 18 and 24 hours in group C (P > 0.05). The first requested time, total used amount of analgesicand pain intensity were not meaningfully different in K-pre and K-post groups (P > 0.05). CONCLUSIONS: Patients who were given ketamine before or after cesarean section subcutaneously at incision site had lower pain intensity and less analgesic consumption than patients who were given placebo.

The Effect of Inhalation of Aromatherapy Blend containing Lavender Essential Oil on Cesarean Postoperative Pain.

BACKGROUND: Pain is a major problem in patients after cesarean and medication such as aromatherapy which is a complementary therapy, in which the essences of the plants oils are used to reduce such undesirable conditions. OBJECTIVES: In this study, the effect of aromatherapy using Lavender (Lavandula) essential oil on cesarean postoperative pain was assessed. MATERIALS AND METHODS: In a triple blind, randomized placebo-controlled trial study, 60 pregnant women who were admitted to a general hospital for cesarean section, were divided randomly into two groups. After cesarean, the Lavender group inhaled about 3 drops of 10% Lavender oil essence and the placebo group inhaled 3 drops of placebo after the start of postoperative pain, four, eight and 12 hours later, for 5 minutes from the 10 cm distance. Patient's pain was measured by the VAS (Visual Analog Scale) score before and after each intervention, and vital sign, complications and level of satisfaction of every patient were recorded before and after aromatherapy. RESULTS: There was no statistically significant difference between groups in age, height, weight, and time to the first analgesic requirement. Patients in the Lavender group had less postoperative pain in four (P = 0.008), eight (P = 0.024) and 12 (P = 0.011) hours after first medication than the placebo group. The decreased heart rate and patients' level of satisfaction with analgesia were significantly higher in the Lavender group (P = 0.001). In the placebo group, the use of diclofenac suppositories for complete analgesia was also significantly higher than the Lavender group (P = 0.008). CONCLUSIONS: The inhaled Lavender essence may be used as a part of the multidisciplinary treatment of pain after cesarean section, but it is not recommended as the sole pain management.

Evaluation of oral zinc sulfate effect on obsessive-compulsive disorder: a randomized placebo-controlled clinical trial.

OBJECTIVE: Obsessive-compulsive disorder is a common neuropsychiatric condition. Although various pharmaceutical agents are available for the treatment of obsessive-compulsive disorder, psychiatrists often find that many patients cannot tolerate the side effects of these medications, the patients do not respond properly to the treatment, or the medications lose their effectiveness after a period of treatment. The augmentation with safe supplementation of medication, such as with trace elements, may be a solution to some of these problems. METHODS: This study was a prospective, double-blinded, 8-wk trial. Twelve patients were given fluoxetine (20 mg/d) plus zinc (440 mg/d) and 11 patients were given fluoxetine plus placebo for 8 wk. RESULTS: Both groups showed a decrease in the mean Yale-Brown Obsessive-Compulsive Scale score. Based on t tests, in weeks 2 and 8, patients treated with fluoxetine plus zinc had significantly lower scores than those treated with fluoxetine plus placebo. CONCLUSION: The results show that zinc, as adjuvant agent for obsessive-compulsive disorder, produces improved outcomes.