The Effect of Ultra-low-dose Intrathecal Naloxone on Pain Intensity After Lumbar Laminectomy With Spinal Fusion: A Randomized Controlled Trial.

BACKGROUND: Despite advances in pain management, several patients continue to experience severe acute pain after lumbar spine surgery. The aim of this study was to assess the safety and effectiveness of single ultra-low-dose intrathecal (IT) naloxone in combination with IT morphine for reducing pain intensity, pruritus, nausea, and vomiting in patients undergoing lumbar laminectomy with spinal fusion. MATERIALS AND METHODS: In this double-blind trial, patients scheduled for lumbar laminectomy with spinal fusion were randomly assigned to receive single ultra-low-dose IT naloxone (20 µg) and IT morphine (0.2 mg) (group M+N) or IT morphine (0.2 mg) alone (group M). The severity of postoperative pain, pruritus and nausea, and frequency of vomiting were assessed at recovery from anesthesia and, subsequently, at 1, 3, 6, 12, and 24 hours postoperatively using an 11-point (0-10) visual analogue scale. RESULTS: A total of 77 patients completed the study, and there were significant differences in postoperative pain, pruritus, and nausea visual analogue scale between the groups (P<0.05). After adjusting for body mass index and surgery duration, IT naloxone administration reduced the pain score (coefficient=1.84; 95% confidence interval [CI], 1.05-2.63; P<0.001), and the scores of pruritus and nausea (coefficient=0.9; 95% CI, 0.44-1.37; P<0.001 and coefficient=0.71; 95% CI, 0.12-1.31; P=0.02, respectively) compared with IT morphine alone. No serious adverse effects were observed. CONCLUSIONS: The addition of ultra-low-dose IT naloxone to IT morphine provides excellent postoperative pain management and effectively controls pruritus and nausea in patients undergoing laminectomy with spinal fusion.

Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review.

Capnograph is an indispensable tool for monitoring metabolic and respiratory function. In this study, the aim was to review the applications of end-tidal carbon dioxide (ETCO2) monitoring in emergency department, multiple databases were comprehensively searched with combination of following keywords: "ETCO2", "emergency department monitoring", and "critical monitoring" in PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and Cochrane Database.

Ultra-low-dose Naloxone as an Adjuvant to Patient Controlled Analgesia (PCA) With Morphine for Postoperative Pain Relief Following Lumber Discectomy: A Double-blind, Randomized, Placebo-controlled Trial.

BACKGROUND: Lumbar discectomy is one of the most commonly performed neurosurgical procedures. Many patients experience postoperative pain after lumbar discectomy. This study evaluated the effect of ultra-low-dose naloxone infusion on pain intensity after lumbar discectomy in individuals receiving patient-controlled analgesia (PCA) with morphine. MATERIALS AND METHODS: In a double-blind, randomized, controlled trial, a total of 80 patients scheduled for open discectomy was randomly assigned to receive naloxone (group N) or placebo (group P). After surgery, all patients were connected to a morphine PCA pump. Both groups received 500 mL of normal saline using a continuous infusion pump through a separate intravenous line for 24 hours. However, group N received a total dose of 0.25 µg/kg/h naloxone, which was added to the normal saline infusion. All patients were asked to grade the intensity of their pain, severity of nausea, vomiting, and pruritus on a 0 to 10 visual analog scale before being discharged from the postanesthesia care unit and at 1, 6, 12, and 24 hours postoperatively. RESULTS: It was observed that both groups had a statistically significant (P<0.01) time trend difference for pain, nausea, and pruritus scores. A significant difference was found between the 2 groups in terms of intensity of pain, nausea, and pruritus, with the naloxone group experiencing a lower level in comparison with the placebo group. Moreover, the median (interquartile range) of morphine consumption after surgery for patients who received naloxone was 26 (24.25 to 28) mg, which is significantly (P<0.001) lower than for the placebo group, which had a median (interquartile range) of 34 (32 to 36) mg. CONCLUSIONS: It is concluded that infusion of ultra-low-dose naloxone (0.25 µg/kg/h) along with morphine PCA can significantly reduce pain intensity, morphine consumption, and opioid-induced nausea and pruritus after lumbar discectomy.

Effect of Etomidate Versus Combination of Propofol-Ketamine and Thiopental-Ketamine on Hemodynamic Response to Laryngoscopy and Intubation: A Randomized Double Blind Clinical Trial.

BACKGROUND: Laryngoscopy and intubation frequently used for airway management during general anesthesia, is frequently associated with undesirable hemodynamic disturbances. OBJECTIVES: The aim of this study was to compare the effects of etomidate, combination of propofol-ketamine and thiopental-ketamine as induction agents on hemodynamic response to laryngoscopy and intubation. PATIENTS AND METHODS: In a double blind, randomized clinical trial a total of 120 adult patients of both sexes, aged 18 - 45 years, scheduled for elective surgery under general anesthesia were randomly assigned into three equally sized groups. Patients in group A received etomidate (0.3 mg/kg) plus normal saline as placebo. Patients in group B and C received propofol (1.5 mg/kg) plus ketamine (0.5 mg/kg) and thiopental sodium (3 mg/kg) plus ketamine (0.5 mg/kg), respectively for anesthesia induction. Before laryngoscopy and tracheal intubation, immediately after, and also one and three minutes after the procedures, hemodynamic values (SBP, DBP, MAP and HR) were measured. RESULTS: A repeated measurement ANOVA showed significant changes in mean SBP and DBP between the time points (P < 0.05). In addition, the main effect of MAP and HR were statistically significant during the course of study (P < 0.05). Furthermore, after induction of anesthesia, the three study groups had significantly different SBP, DBP and MAP changes overtime (P < 0.05). However, HR changes over time were not statistically significant (P > 0.05). Combination of propofol-ketamine had superior hemodynamic stability compared to other induction agents. CONCLUSIONS: Combination of propofol-ketamine may be recommended as an effective and safe induction agent for attenuating hemodynamic responses to laryngoscopy and intubation with better hemodynamic stability. Although, further well-designed randomized clinical trials to confirm the safety and efficacy of this combination, especially in critically ill patients or patients with cardiovascular disease, are warranted.

Comparison of Proposed Modified and Original Sequential Organ Failure Assessment Scores in Predicting ICU Mortality: A Prospective, Observational, Follow-Up Study.

Background. The sequential organ failure assessment (SOFA) score has been recommended to triage critically ill patients in the intensive care unit (ICU). This study aimed to compare the performance of our proposed MSOFA and original SOFA scores in predicting ICU mortality. Methods. This prospective observational study was conducted on 250 patients admitted to the ICU. Both tools scores were calculated at the beginning, 24 hours of ICU admission, and 48 hours of ICU admission. Diagnostic odds ratio and receiver operating characteristic (ROC) curve were used to compare the two scores. Results. MSOFA and SOFA predicted mortality similarly with an area under the ROC curve of 0.837, 0.992, and 0.977 for MSOFA 1, MSOFA 2, and MSOFA 3, respectively, and 0.857, 0.988, and 0.988 for SOFA 1, SOFA 2, and SOFA 3, respectively. The sensitivity and specificity of MSOFA 1 in cut-off point 8 were 82.9% and 68.4%, respectively, MSOFA 2 in cut-off point 9.5 were 94.7% and 97.1%, respectively, and MSOFA 3 in cut-off point of 9.3 were 97.4% and 93.1%, respectively. There was a significant positive correlation between the MSOFA 1 and the SOFA 1 (r: 0.942), 24 hours (r: 0.972), and 48 hours (r: 0.960). Conclusion. The proposed MSOFA and the SOFA scores had high diagnostic accuracy, sensitivity, and specificity for predicting mortality.

Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial.

OBJECTIVE: Renal colic (RC) is a common clinical presentation in the emergency department (ED). Prompt and effective pain control is one of the first responsibilities of emergency physicians. The aim of this study was to evaluate the analgesic effect of adding lidocaine to morphine compared to morphine alone in patients presenting to the ED with RC. METHODS: In a double-blind, randomized controlled trial, a total of 110 adult patients of both sexes, aged 18 to 50 years, who presented to the ED with signs and symptoms suggestive of RC were randomly assigned into 1 of 2 groups. Patients in group A received morphine (0.1 mg/kg) plus lidocaine (1.5 mg/kg), whereas those in group B received morphine (0.1 mg/kg) plus normal saline 0.9% as placebo. All patients were asked to rate the intensity of their pain and nausea on a 0- to 10-point visual analog scale before and at 5, 10, 30, 60, and 120 minutes after intervention. RESULTS: There was a statistically significant time trend decline in both groups for both pain and nausea scores (P < .01). Repeated-measures analysis showed a significant effect for the interaction between group and time of persistent pain (P = .034), but there was no significant group effect in this regard (P = .146). Median times to being pain free in the group receiving morphine plus lidocaine and in the group taking morphine alone were 87.02 minutes (95% confidence interval [CI], 74.23-94.82) and 100.12 minutes (95% CI, 89.95-110.23), respectively (P = .071). Repeated-measures analysis also showed a significant group effect for nausea (P = .038), but there was no interaction between group and time in this regard (P = .243). The median nausea-free times in the group receiving morphine plus lidocaine and the group receiving morphine alone were 26.6 minutes (95% CI, 14.16-39.03) and 58.33 minutes (95% CI, 41.85-74.82), respectively. This time difference was statistically significant (P < .001). CONCLUSIONS: Using lidocaine may be recommended as an effective, safe, and inexpensive adjuvant to morphine in improving nausea and reducing the time needed to achieve pain and nausea relief in patients visiting the ED with acute RC.