Pilot prospective open-label one-arm trial investigating intrathecal Adenosine in neuropathic pain after lumbar discectomy

Objectives

Adenosine has an analgesic and anti-inflammatory role and its injections are used for perioperative pain management. We aimed to study efficacy of intrathecal injection of adenosine for post-operative radicular pain after lumbar discectomy. Forty patients with unilevel lumbar discectomy who had radicular lower limb pain were treated by 1000 micrograms of intrathecal injection of adenosine in this single-arm prospective open-label trial between November 2015 to October 2016. Radicular pain severity using visual analogue scale (VAS) and pain killer consumption per day were assessed during a 3 months follow up period.

Results

Radicular pain severity was significantly reduced in 3 month follow-up period in comparison to the baseline (F = 19,760, df = 2.53, p-value < 0.001). Further, painkiller medication consumption rate in average during 3 month follow-up period after injection was significantly lower in comparison to baseline (F = 19.244, df = 1.98, p-value < 0.001). This study suggests that intrathecal injection of 1000 micrograms adenosine is a safe and effective method for post-operative neuropathic pain management after uni-level disk surgeries.

Trial registration IRCT201608171772N20, Retrospectively registered on 2016-08-28.

Effect of Dexmedetomidine Combined with Inhalation of Isoflurane on Oxygenation Following One-Lung Ventilation in Thoracic Surgery

Background

One-lung ventilation (OLV) is commonly used during thoracic surgery. At this time, hypoxemia is considered one of the remarkable consequences of the anesthesia management. Hypoxic pulmonary vasoconstriction (HPV) is the defense mechanism against hypoxia.

Objectives

The aim of the present study was to investigate the effect of infusion of dexmedetomidine on improving the oxygenation during OLV among the adult patients undergoing thoracic surgery.

Methods

A total of 42 patients undergoing OLV by general anesthesia with isoflurane inhalation were randomly assigned into two groups: IV infusion of dexmedetomidine at 0.3 microgram/kg/h (DISO) and IV infusion of normal saline (NISO). Three Arterial Blood Gas (ABG) samples were obtained throughout the surgery. Hemodynamic parameters, PaO₂, PaCO₂, and complications at recovery phase were recorded. The collected information was analyzed using SPSS software version 22.

Results

In the dexmedetomidine group, the mean hemodynamic parameters had a significant reduction at 30 and 60 minutes following OLV. Administration of dexmedetomidine resulted in a significant increase in the PaCO₂ and a reduction in the PaO₂ when changing from two-lung ventilation to OLV, where PaO₂ reached its maximum value within 10 minutes after OLV in the DISO group, and it began to gradually increase to the end of operation. The duration of the recovery phase, also complications at the recovery phase decreased significantly in DISO group.

Conclusions

The results of the study showed that, dexmedetomidine may improve arterial oxygenation during OLV in adult patients undergoing thoracic surgery, and can be a suitable anesthetic agent for thoracic surgery.

Comparing the efficacy of intravenous acetaminophen and intravenous meperidine in pain relief after outpatient urological surgery

Background:

Pain relief after surgery is an essential component of postoperative care.

Objectives:

The purpose of this study was to compare the efficacy of intravenous acetaminophen and intravenous meperidine in pain relief after outpatient urological surgery.

Patients and Methods:

In a prospective, randomized, double-blind clinical trial, 100 outpatients of urological surgery were studied in two groups of acetaminophen (A) and meperidine (M). Patients in group A received 1g of acetaminophen in 100 mL saline within 15 minutes and patients in group M received a single intravenous injection of meperidine 0.5 mg/kg, 15 minutes prior to the end of operation. Postoperative pain was recorded using visual analog scale (VAS). Vital signs, nausea, vomiting, dizziness and respiratory depressions were compared between the two groups.

Results:

Pain severity in patients treated with intravenous acetaminophen six hours after the operation within one-hour interval was significantly lower than meperidine group (P < 0.0001). Ninety patients in the meperidine group and five patients in the acetaminophen group required additional doses of analgesics. Nausea was significantly lower in acetaminophen group than meperidine group.

Conclusions:

Intravenous acetaminophen reduced pain following outpatient urological surgery more significantly than meperidine.

Postoperative Management of Shivering: A Comparison of Pethidine vs. Ketamine

Background:

One of the unpleasant side effects of general anesthesia is shivering in the process of recovery. It is an involuntary oscillatory mechanical movement that can be classified as clonic movements. These movements can affect one or several groups of skeletal muscles beginning from 5 to 30 minutes after the discontinuation of anesthesia.

Objectives:

We aimed to study ketamine’s effect on shivering after operation compared to pethidine as a way for treatment of postoperative shivering.

Patients and Methods:

In this study, 60 patients who underwent ENT surgery with general anesthesia and had shivering during recovery were randomly divided into two groups of 30 patients each receiving ketamine (0.2 mg/kg IV) and pethidine (0.5 mg/kg).

Results:

There was no statistically significant difference between the shivering intensity in both groups. Only regarding the shivering in the first minute after entering the recovery room, there was an obvious difference between ketamine and pethidine groups which was again not statistically significant (P = 0.07).

Conclusions:

The results of this study showed that ketamine and pethidine are both equally effective in the reduction of postoperative shivering.

Vocal cord paralysis and its etiologies: a prospective study

Introduction: Vocal cord paralysis is a common symptom of numerous diseases and it may be due to neurogenic or mechanical fixation of the cords. Paralysis of the vocal cords is just a symptom of underlying disease in some cases; so, clinical diagnosis of the underlying cause leading to paralysis of the vocal cords is important. This study evaluates the causes of vocal cord paralysis.

Methods: In a prospective study, 45 patients with paralyzed vocal cord diagnosis were examined by tests such as examination of the pharynx, larynx, esophagus, thyroid, cervical, lung, and mediastinum, brain and heart by diagnostic imaging to investigate the cause vocal cord paralysis. The study was ended by diagnosing the reason of vocal cord paralysis at each stage of the examination and the clinical studies.

Results: The mean duration of symptoms was 18.95±6.50 months. The reason for referral was phonation changes (97.8%) and aspiration (37.8%) in the subjects. There was bilateral paralysis in 6.82%, left paralysis in 56.82% and right in 63.36% of subjects. The type of vocal cord placement was midline in 52.8%, paramedian in 44.4% and lateral in 2.8% of the subjects. The causes of vocal cords paralysis were idiopathic paralysis (31.11%), tumors (31.11%), surgery (28.89%), trauma, brain problems, systemic disease and other causes (2.2%).

Conclusion: An integrated diagnostic and treatment program is necessary for patients with vocal cord paralysis. Possibility of malignancy should be excluded before marking idiopathic reason to vocal cord paralysis.

Comparison of postoperative complication between Laryngeal Mask Airway and endotracheal tube during low-flow anesthesia with controlled ventilation

OBJECTIVE

To compare the postoperative complications between Laryngeal Mask Airway (LMA) and endotracheal tube (ETT) during low-flow anesthesia with controlled ventilation.

METHODOLOGY

Eighty adult Patients with ASA class I or II were randomly allocated into two forty-patient groups (ETT or LMA). Cuff pressure was monitored during anesthesia. After high uptake period, fresh gas flow (FGF) was decreased to 1 lit/min and isoflurane set to 1%. Monitoring during anesthesia included non-invasive blood pressure, ECG, ETCO2 and pulse oximetry. System leakage (>100 ml/min), rebreathing and any attempt to increase FGF to overcome the leak were monitored during anesthesia. Later, patients were extubated and transferred to Post Anesthesia Care Unit (PACU). In PACU, the incidence of sore throat, cough, difficulty in swallowing and shivering was monitored for all patients.

RESULTS

Leakage was observed in two and three cases in ETT and LMA groups respectively (P>0.05). Postoperative cough, sore throat and difficulty in swallowing were significantly less in LMA than ETT group. No significant difference was observed regarding ETCo2 values between 2 groups.

CONCLUSION

If careful measures regarding insertion techniques, correct LMA position and routine monitoring of LMA cuff pressure are taken, LMA can be used as a safe alternative with lower incidence of post operation complication compared with ETT during low-flow controlled anesthesia with modern anesthetic machines.

Assessment of Mini-dose Succinylcholine Effect on FacilitatingLaryngeal Mask Airway Insertion

INTRODUCTION

Laryngeal Mask Airway (LMA) has gained wide acceptance for routine airway management and with increasing emphasis on day care surgery it is widely used. The aim of this study was to assess the effects of mini dose succinylcholine (0.1mg/kg) with semi-inflated cuff on facilitation of laryngeal mask airway insertion in order to achieve more satisfaction yet less complications .

METHODS

In a randomized double-blinded study, sixty ASA 1, 2 and 3 patients aged 20-60 years scheduled for urologic surgical procedures were included. Thirty patients received succinylcholine (Group S), and thirty received 0.9% sodium choride as a placebo (Group C).

RESULTS

Coughing occured in 33.3% of patients in the control group and there was no incidence in succ group (P=0.002). Head or limb movement occurred in 70% of the patients in the control group vs. 10% in succ group (P<0.001). Laryngospasm occurred in 36.6 % of the patients in the control group but there was no incidence in succ group (P=0.004). Additional propofol was required in 53% of the patients in control group vs. 10% for succ group (P=0.001). Ease of insertion and first successfull attempt of LMA were achieved in 93.3% and 90% of the patients respectively in group S (P<0.05). Myalgia and sore throat occurred in 66.7 % of patients in the group C in comparison with 33.3% in group S (P=0.06).

CONCLUSION

The combination of propofol with mini dose succinylcholine, provided a significantly better method for LMA insertion, while reduced propofol doses were needed and number of attempts decreased.

Effect of Intravenous Hydrocortisone on Preventing Postoperative Sore Throat Followed by Laryngeal Mask Airway Use in patients Undergoing Urogenital Surgeries

INTRODUCTION

Postoperative sore throat is a common complication which can lead to discomfort after operation and delay in patients' returning to normal daily activities. The present study was carried out to evaluate the influence of intravenous hydrocortisone on preventing postoperative sore throat followed by laryngeal mask airway use.

METHODS

Sixty patients who were scheduled to undergo urogenital surgery were divided into two groups. Five minutes before anesthesia induction, 100 mg of intravenous hydrocortisone or placebo with the same volume were given to the patients randomly. At the end of the operation and after LMAs were removed, patients were asked about having sore throat at hours 2, 4 and 24 after operation.

RESULTS

There were three and six cases of sore throat after operation in hydrocortisone and in placebo groups respectively which showed no significant statistical difference (P=0.472). No cases of moderate or severe pain were reported in any of the patients in both groups and no statistically significant difference was observed regarding pain severity in recovery, hours 2, 4 or 24 after operation.

CONCLUSION

Based on the statistical data obtained from this research, administrating intravenous hydrocortisone five minutes before anesthesia induction has no effect on postoperative sore throat severity and degree in urogenital surgeries.

Administration of Remifentanil in Establishing a more Stable Post-anesthesia Cardiovascular Status in Neurosurgical Procedures

INTRODUCTION

Emergence from general anesthesia and especially post-extubation phase are the stages associated with cardiovascular hyperdynamic status in which patients with increased intracranial pressure (ICP) could be affected by severe cardiac and or cerebral complications. Administering remifentanil could be helpful in maintaining the hemodynamic stability at the end of the surgery and recovery stages and reducing recovery phase length.

METHODS

In a double-blind prospective randomized clinical trial, 60 adult patients with ASA (American Society of Anesthesiologist) class of I-II scheduled to undergo elective neurosurgery operations were randomly divided into two groups receiving remifentanil and placebo as IV infusion within four minutes prior to extubation continued by an IV infusion for 10 minutes after extubation.

RESULTS

There was a significant difference between two groups regarding the changes of Mean Arterial Pressure after extubation and five minutes after extubation (P˂ 0.001).Remifentanil group compared with control group was of significant difference at all heart rate values after extubation (P< 0.001).

CONCLUSION

Remifentanil could be used in preventing hyperdynamic status throughout extubation phase without extending recovery phase length. However, administration of this medication should be performed cautiously.