Effect of adding dexmedetomidine on two methods of labor analgesia via epidural among parturient patients.

Background: Continuous epidural infusion (CEI) has been an optimal and acceptable technique for inducing epidural anesthesia. This study compared two methods of programmed intermittent epidural bolus (PIEB) with CEI in labor analgesia among patients receiving epidural dexmedetomidine. Methods: This study was a randomized clinical trial. The target population was term women candidates for epidural anesthesia. After selection of sample size based on inclusion criteria, a total of 3 cc of dexmedetomidine (0.5 µg/ml) and Ropivacaine 0.1% was injected. Furthermore, 5 ml was injected as a loading dose of dexmedetomidine 0.5 µg /ml and Ropivacaine 0.1%. Then the pain score was recorded. SPSS software Version 23 was used for statistical analysis of data. Results: The neonatal Apgar score in PIEB method was more improved (P = 0.003) and the use of assisted delivery tools such as vacuum, in PIEB method was reduced. (p=0.038) Duration of the first phase of the labor in this method was more reduced than CEI.(p=0.015) Patients in the group undergoing epidural anesthesia by PIEB method were associated with a higher level of satisfaction with the delivery process (p < 0.05) than patients undergoing CEI protocol. Conclusion: PIEB method is associated with further improvement in neonatal Apgar score and maternal outcomes (reduction in the duration of the first phase of labor and no need to use assisted delivery methods) compared to the CEI protocol, but has little effect on hemodynamic conditions or drug dosage.

Comparison of Fat-Free Mass and Ideal Body Weight Scalar for Anesthetic Induction Dose of Propofol in Patients with Morbid Obesity: A Double-Blind, Randomized Clinical Trial.

Background: Obesity is a growing problem worldwide and can affect both the pharmacodynamics and pharmacokinetics of various drugs, including anesthetics, resulting in the under-or overdosing of certain drugs. There is no consensus on the ideal dosing regimen for obese populations. Objectives: In this study, 2 weight-based dosing of propofol used for induction of anesthesia were compared in terms of the onset of action time, adequacy of anesthesia, and effects on hemodynamic indices (eg, heart rate [HR] and blood pressure). Methods: In this randomized, double-blind clinical trial, 40 patients with morbid obesity (MO) scheduled for bariatric surgery with body mass index (BMI) > 35, age 18 - 59 years, American Society of Anesthesiologists physical status (ASA-PS) II and III were randomly divided into 2 groups, using block randomization method, to receive 2 mg/kg of propofol for induction of anesthesia based on either fat-free mass (FFM) group or ideal body weight (IBW) group. The primary outcome was the time duration to reach the bispectral index (BIS) ≤ 60. Time to the disappearance of eyelash reflex, signs of inadequate anesthesia (ie, BIS > 60, straining during intubation, or eye-opening), requirements for additional doses, and hemodynamic indices (including HR and mean arterial pressure [MAP]) were also compared. Results: The mean time to reach BIS ≤ 60 was 134.1 s in the FFM group and 148.7 s in the IBW group. This difference was not statistically significant (P = 0.334). The time of disappearance of eyelash reflex was also not significantly different between the study groups (P = 0.814). However, 2 patients in the FFM group and 8 patients in the IBW group showed signs of inadequate anesthesia and required additional doses. This difference was statistically significant (P = 0.032). Hemodynamic variables, before and 2 min after propofol induction dose administration were comparable between the study groups (P = 0.520, P = 0.327, P = 0.847, P = 0.516 for pre-intervention MAP, post-intervention MAP, pre-intervention HR, and post-intervention HR, respectively). Conclusions: Propofol dosing, based on FFM and IBW, for induction of anesthesia, provides comparable onset time of action and hemodynamic effects; however, in terms of the adequacy of anesthesia, the dosing based on FFM is more favorable compared to the dosing based on IBW.

Effect of bupivacaine intraperitoneal and intra-abdominal bicarbonate in reducing postoperative pain in laparoscopic cholecystectomy: a double-blind randomized clinical trial study.

OBJECTIVE: We aimed to compare the effect of bupivacaine intraperitoneal with intra-abdominal bicarbonate in reducing postoperative pain in laparoscopic cholecystectomy. RESULTS: In this double-blind randomized clinical trial study, 58 patients underwent laparoscopic cholecystectomy referred to a hospital in Tehran, Iran (2019), were assigned into three groups: at the end of the surgery, spraying 50 cc of bupivacaine 0.2% through the laparoscopic port; or rinsing the abdomen with 5.7% bicarbonate dissolved in 1000 cc of normal saline; or abdominal lavage with normal saline. Pain of patients was evaluated according to visual analogue scale criteria and means Ramsay score in recovery times, 2, 8 and 24 h and post-operative analgesia satisfaction score at 2 and 24 h were also evaluated. The mean age of range was 44.26 ± 13.13 years, 44 female patients and 14 male patients. The mean Ramsay score in recovery, 2, 8 and 24 h postoperative times was not significantly different among the groups. Comparing post-operative analgesic satisfaction scores in recovery, 2 and 24 h revealed no significant difference among the groups. We found that use of bupivacaine intraperitoneal and intra-abdominal bicarbonate decreased pain after laparoscopic cholecystectomy but the decrease was more in bupivacaine group than bicarbonate group. TRIAL REGISTRATION: Retrospectively registered, IRCT20180723040570N1; date of registration: 2019-06-24.

Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future.

The treatment of pain, both acute and chronic, has been a focus of medicine for generations. Physicians have tried to develop novel ways to effectively manage pain in surgical and post-surgical settings. One intervention demonstrating efficacy is nerve blocks. Single-injection peripheral nerve blocks (PNBs) are usually preferred over continuous PNBs, since they are not associated with longer lengths of stay. The challenge of single injection PNBs is their length of duration, which at present is a major limitation. Novel preparations of local anesthetics have also been studied, and these new preparations could allow for extended duration of action of anesthetics. An emerging preparation of bupivacaine, exparel, uses a multivesicular liposomal delivery system which releases medication in a steady, controlled manner. Another extended-release local anesthetic, HTX-011, consists of a combination of bupivacaine and low-dose meloxicam. Tetrodotoxin, a naturally occurring reversible site 1 sodium channel toxin derived from pufferfish and shellfish, has shown the potential to block conduction of isolated nerves. Neosaxitoxin is a more potent reversible site 1 sodium channel toxin also found in shellfish that can also block nerve conduction. These novel formulations show great promise in terms of the ability to prolong the duration of single injection PNBs. This field is still currently in development, and more researchers will need to be done to ensure the efficacy and safety of these novel formulations. These formulations could be the future of pain management if ongoing research continues to prove positive effects and low side effect profiles.

The Effect of Painless Delivery with Intrathecal Sufentanil on Labor Progress and Neonatal Outcomes: A Single Center Study on Pregnant Women.

Background: Delivery pain is the most unbearable pain and can be relieved with intrathecal opioids. This study aimed to investigate the effect of intrathecal sufentanil for painless delivery on labor progress and neonatal outcomes in pregnant women. Methods: This was a single-arm observational cohort study on 1055 pregnant women candidates for vaginal delivery with spinal analgesia referred to the Akbarabadi Hospital. First, 0.1 µg/kg of intrathecal sufentanil was used, and maternal blood pressure and maternal and fetal heart rates were recorded after analgesia. During delivery, the mothers were monitored for nausea, pruritus, motor block, apnea, urinary retention, or the possibility of an emergency cesarean section. The duration of the analgesia, the duration of the second stages of labor, and the mother's pain scores were recorded based on the Visual Analogue Scale (VAS). 1- and 5-minute Apgar scores and arterial blood gas (ABG) of the umbilical cord were also recorded. Results: The most common station was -3 for 723 women, followed by -2 for 229 women. Fifty-two women underwent cesarean section, and fetal distress was the most common reason for cesarean section (57.7%). The mean time for initiating analgesia was 5.93 ± 2.87 minutes, and the mean visual analog scale was 1.08 ± 0.16. The mean Apgar was 9.0 ± 0.47; the mean weight at birth was 2917.39 ± 449.90 gr; PH was 7.31 ± 2.03; HCO3 was 22.67 ± 3.08mEq/liter, and PaCo2 was 43.36 ± 7.06 mmHg. Regarding complications, the patients just developed itching (n = 78), and hypotension, bradycardia, apnea, and decreased consciousness were overlooked. Conclusions: Intrathecal sufentanil is safe and efficient in painless delivery, resulting in normal Apgar and normal PH with no specific side-effect.

The Effect of Phenylephrine Infusion on Maternal Hemodynamic Changes During Spinal Anesthesia for Cesarean Delivery.

BACKGROUND: Spinal anesthesia is used as a common anesthetic technique in many routine and outpatient surgeries. OBJECTIVES: The aim of this study was to determine the effect of phenylephrine on maternal hemodynamic changes during spinal anesthesia for cesarean delivery. METHODS: This double-blind randomized controlled trial was conducted on 116 pregnant women candidate for the elective cesarean section through spinal anesthesia in the Shahid Akbarabadi Hospital, Tehran in 2019. The eligible women were randomly divided into the intervention (phenylephrine; n = 58) and control (normal saline; n = 58) groups. The data collection tool was a checklist, including the demographic and clinical variables, such as age, height, weight, body mass index, gravid, gestational age, Apgar score of 1 and 5, systolic blood pressure, diastolic blood pressure, heart rate, mean arterial pressure, SPO2, PH of the umbilical cord, PCO2, HCO3, base excess, nausea, and vomiting. Data were analyzed using SPSS 24 software and P value < 0.05 was considered as significant. RESULTS: The intervention and control groups showed a significant difference in terms of the PH of the umbilical cord, PCO2, and nausea and vomiting (P value < 0.05). The results of the repeated measure ANOVA test showed a significant statistical difference between the intervention and control groups at different time points in terms of arterial pressure, systolic and diastolic blood pressures (P value < 0.05). CONCLUSIONS: Phenylephrine is effective in the prevention of some complications, like reducing mean arterial pressure, systolic and diastolic blood pressures, nausea, and vomiting during spinal anesthesia for cesarean delivery. Therefore, these drugs can be used based on maternal hemodynamic status during spinal anesthesia for cesarean delivery.

Which Ultrasound-Guided Sciatic Nerve Block Strategy Works Faster? Prebifurcation or Separate Tibial-Peroneal Nerve Block? A Randomized Clinical Trial.

BACKGROUND: Peripheral nerve block is an accepted method in lower limb surgeries regarding its convenience and good tolerance by the patients. Quick performance and fast sensory and motor block are highly demanded in this method. The aim of the present study was to compare 2 different methods of sciatic and tibial-peroneal nerve block in lower limb surgeries in terms of block onset. METHODS: In this clinical trial, 52 candidates for elective lower limb surgery were randomly divided into 2 groups: sciatic nerve block before bifurcation (SG; n = 27) and separate tibial-peroneal nerve block (TPG; n = 25) under ultrasound plus nerve stimulator guidance. The mean duration of block performance, as well as complete sensory and motor block, was recorded and compared between the groups. RESULTS: The mean duration of complete sensory block in the SG and TPG groups was 35.4 ± 4.1 and 24.9 ± 4.2 minutes, respectively, which was significantly lower in the TPG group (P = 0.001). The mean duration of complete motor block in the SG and TPG groups was 63.3 ± 4.4 and 48.4 ± 4.6 minutes, respectively, which was significantly lower in the TPG group (P = 0.001). No nerve injuries, paresthesia, or other possible side effects were reported in patients. CONCLUSIONS: According to the present study, it seems that TPG shows a faster sensory and motor block than SG.