Erector spinae plane block as an anesthesia technique for an emergent thoracotomy; a case report

BACKGROUND

The erector spinae plane block (ESPB) is a novel regional block technique for pain management following thoracic surgeries. However, there are minimal cases in which the technique was used as the main anesthesia technique during surgery.

CASE PRESENTATION

Here, we report the successful use of ESBP for applying anesthesia in a case during an emergent thoracotomy for performing pericardiotomy and loculated tamponade evacuation.

CONCLUSIONS

Using ESPB with a higher concentration of local anesthetics, in this case, prepared appropriate anesthesia for performing an emergent thoracotomy while avoiding multiple needle insertions and the risk of further hemodynamic instability.

Efficacy Comparison Between Interscalene Block with and Without Superficial Cervical Plexus Block for Anesthesia in Clavicle Surgery

Background

Clavicle fractures account for over one-third of shoulder injuries and up to 3.3% of all fractures in adults. While the majority of these fractures can be managed non-surgically, there are instances where surgical intervention is performed. Regional anesthesia (RA) can be a preferred alternative to general anesthesia (GA) to avoid complications and high costs in this surgery. Moreover, the identification of the most optimal approach for RA remains challenging.

Objectives

This study aimed to compare the efficacy of interscalene block (ISB) with and without superficial cervical plexus block (SCPB) as an anesthetic technique for clavicular fracture operation.

Methods

This double-blinded, non-inferiority clinical trial was conducted on 120 patients randomly divided into 2 groups: One receiving ISB and the other receiving ISB with SCPB. The primary outcome was defined as the conversion to GA. Various factors were recorded, including surgery duration, nerve block initiation, analgesics required in the postanesthesia care unit (PACU), and sedation during surgery. Pain was evaluated using the Visual Analog Scale (VAS) in PACU. SPSS version 26 was used for statistical analysis, performing descriptive analysis, Student's t-tests, and Mann-Whitney U tests to compare non-parametric variables between the 2 groups. Statistically significant results had a P value of less than 0.05.

Results

A total of 120 patients were randomly divided into 2 equal groups, each consisting of 50 males and 10 females. The mean age of intervention and case groups were 37.23 ± 13.30 and 38.43 ± 11.95 years, respectively. After performing statistical tests (Student's t-test and Mann-Whitney U test), there was no significant difference in the initiation time of nerve block, surgery initiation time, surgery duration, the amount of required sedation, VAS scores, and meperidine consumption (P > 0.05). None of the patients in both groups required conversion to GA.

Conclusions

The primary goal was achieved in all included cases, and no patients required conversion to GA. The efficacy of ISB is the same whether or not it is combined with a SCPB. Interscalene block is an alternative RA approach for clavicle fractures. Thus, ISB alone is as efficient as when used in combination with SCPB.

Quadratus Lumborum Block versus Fascia Iliaca Compartment Block for Acetabular Fracture Surgery by Stoppa Method: A Double-Blind, Randomized, Noninferiority Trial

Background

Acetabular fracture surgeries are frequently accompanied by protracted and severe perioperative pain, and there is no consensus on optimal pain relief management.

Aim

This study aimed at comparing the analgesic efficacy of fascia iliaca compartment block (FICB) and quadratus lumborum block (QLB) in patients with acetabular fractures undergoing surgery using the Stoppa method.

Methods

In this double-blind, randomized, noninferiority clinical trial, adult patients undergoing spinal anesthesia for acetabular fracture surgery, in Imam Hossein Hospital, Tehran, Iran (IRCT20191114045435N1), were randomly divided into two groups: FICB (n = 22) and QLB (n = 24). The visual analog scale (VAS) was used to assess the pain intensity at different times for all participants. In addition, the dose of fentanyl required to induce the patient to sit for spinal anesthesia and the pain intensity were evaluated. Moreover, the duration of analgesia and the total amount of morphine consumed in the first 24 h following surgery were evaluated, analyzed, and compared between the two study groups.

Results

FICB and QLB demonstrated effective comparative postoperative analgesic profiles following acetabular fracture surgery; however, no significant differences in VAS values were observed between the two groups during the study. FICB experienced reduced cumulative fentanyl consumption during spinal anesthetic placement, whereas QLB had a significantly lower total morphine demand in the initial postoperative 24 h period.

Conclusion

The lateral QLB and FICB can be introduced as effective routes for analgesia in acetabular fracture surgery using the Stoppa method. Clinical Trial Registration. The study was prospectively registered in the clinical trials registry system, on 2021-02-17, with registration number: IRCT20191114045435N1.

The Effect of Intravenous Metoclopramide on Gastric Emptying of Opium-dependent Patients based on Ultrasonographic Criteria; a Case-control Study

Introduction

Induction of anesthesia for emergency procedures, without prior gastric preparation and incomplete fasting, is associated with the risk of reflux of stomach contents and aspiration. This study aimed to evaluate the effect of intravenous (IV) metoclopramide administration on gastric emptying in opium users, candidate for procedural sedation and analgesia (PSA).

Methods

In the present case-control study, opium-dependent (case) and non-dependent (control) patients in need of PSA were administered with 10 mg IV metoclopramide after undergoing gastric ultrasonography for determination of its area and contents. Then, 30 minutes after the administration of metoclopramide, the area and contents of the stomach were measured again and compared with the measures obtained before the intervention.

Results

135 patients were evaluated in three groups of 45, including the case, control, and placebo groups. The three groups were similar regarding mean age (p = 0.068), sex (p = 0.067), weight (p = 0.596), height (p = 0.671), body mass index (BMI) (p = 0.877), duration of fasting (p = 0.596), and type of gastric contents (p = 0.124). Mean antral cross-sectional area (CSA) of the study participants in the case, control, and placebo groups before the administration of the drug was 8.49 ± 1.40, 8.31 ± 2.56, and 6.56 ± 1.72 cm², respectively. Mean gastric area in the case (p < 0.001) and control (p < 0.001) groups had significantly decreased after the intervention. Mean antral gastric grade of gastric contents in the case (p < 0.001) and control (p < 0.001) groups had significantly decreased after the intervention.

Conclusion

It seems that metoclopramide administration in opium users in need of PSA leads to a significant decrease in mean gastric area and increases gastric emptying.

The Role of Entrustable Professional Activities in Competency-based Medical Education for Anesthesiology Residents: A Pilot Phase

Background

After graduation, physicians should be able to provide professional and safe services without the need for supervision by their clinical professors, mandating a competency-based medical education (CBME) approach.

Objectives

This study aimed to develop a national model of entrustable professional activities (EPAs) based on our experiences in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU).

Methods

The primary EPA design plan was designed in a 10-step model as a career roadmap for the project. The texts were prepared according to a consensus-based approach. On the other hand, the texts were reviewed and revised by a broad team of faculty in a daily workshop.

Results

The final product included 14 topics for EPA as the first round of targeting topics for anesthesiology residents. The texts were developed using previous studies and were standardized considering national standards.

Conclusions

We described a clear path toward designing and implementing EPAs in anesthesiology residency programs to improve the quality of the graduated residents. Though the basic theory is the same, each country needs its formula for implementing the process.

Prediction of Acute Kidney Injury After Cardiac Surgery Using Interpretable Machine Learning

Background

Acute kidney injury (AKI) is a complication that occurs for various reasons after surgery, especially cardiac surgery. This complication can lead to a prolonged treatment process, increased costs, and sometimes death. Prediction of postoperative AKI can help anesthesiologists to implement preventive and early treatment strategies to reduce the risk of AKI.

Objectives

This study tries to predict postoperative AKI using interpretable machine learning models.

Methods

For this study, the information of 1435 patients was collected from multiple centers. The gathered data are in six categories: demographic characteristics and type of surgery, past medical history (PMH), drug history (DH), laboratory information, anesthesia and surgery information, and postoperative variables. Machine learning methods, including support vector machine (SVM), multilayer perceptron (MLP), decision tree (DT), random forest (RF), logistic regression, XGBoost, and AdaBoost, were used to predict postoperative AKI. Local interpretable model-agnostic explanations (LIME) and the Shapley methods were then leveraged to check the interpretability of models.

Results

Comparing the area under the curves (AUCs) obtained for different machine learning models show that the RF and XGBoost methods with values of 0.81 and 0.80 best predict postoperative AKI. The interpretations obtained for the machine learning models show that creatinine (Cr), cardiopulmonary bypass time (CPB time), blood sugar (BS), and albumin (Alb) have the most significant impact on predictions.

Conclusions

The treatment team can be informed about the possibility of postoperative AKI before cardiac surgery using machine learning models such as RF and XGBoost and adjust the treatment procedure accordingly. Interpretability of predictions for each patient ensures the validity of obtained predictions.

Gabapentin as Add-On to Fentanyl and Midazolam in Patients Receiving Mechanical Ventilation: A Randomized, Blinded Study

Objective:

Fentanyl and midazolam are popular drugs for sedation and analgesia in intensive care unit. Gabapentin has sedative and analgesic effects, as well. Our purpose was to study gabapentin addition to fentanyl and midazolam to reach the target sedation level in patients requiring mechanical ventilation.

Methods:

This was a randomized and double-blinded trial. Fifty patients receiving mechanical ventilation and aged from 18 to 70 years were randomized 1 : 1 to 300 mg gabapentin q8hr or placebo. The initial infusion rates of fentanyl and midazolam were 1-2 µg kg^-1 h^-1 and 0.06-0.2 mg kg^-1 h^-1, respectively, in both groups. Treatments continued prior to weaning. Ramsay sedation scale score (2-3) and behavioral pain scale score (≤4) were used for the evaluation of sedation and analgesia levels, respectively.

Results:

A total of 43 patients were studied. Both treatment modalities reached the target sedation and analgesia levels. In the intervention group, there were significant reductions in daily consumption of fentanyl and midazolam (P < .01). Duration of ventilation was shorter in the intervention group (4.1 ± 1.7 days vs 5.1 ± 1.3 days, P > .05). There was no significant difference in intensive care hospitalization, although it was shorter in the intervention group (201 ± 24 hours vs 224 ± 19 hours, P > .05).

Conclusions:

This trail showed that both treatment modalities could reach target sedation and analgesia levels without significant differences. Add-on therapy with gabapentin could reduce the total dose of fentanyl and midazolam.

Comparison of Optic Nerve Sheath Diameter (ONSD) in Low-Pressure Versus Normal Pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Clinical Study

Background: Low pressure laparoscopic cholecystectomy has been advocated due to reduction in postoperative pain, ventilation problems, hemodynamic complications, and potential for reduction in surgical events. No reported data have been found focusing on the effects of low-pressure laparoscopic cholecystectomy on intracranial pressure (ICP). The aim of this study was to investigate the effect of low-pressure laparoscopic cholecystectomy on intracranial pressure measured by optic nerve sheath diameter (ONSD) in Imam Hossein Medical Center, Tehran, Iran.

Methods: The patients classified as American Society of Anesthesiologists physical status I or II undergoing elective laparoscopic cholecystectomy due to benign gallbladder disease were randomly assigned to low-pressure laparoscopy (LPL) group or normal pressure laparoscopy group (NPL). ONSD was measured at 3 different times: (1) before induction of anesthesia; (2) after initiation of gas insufflation; and (3) after the termination of gas insufflation. The collected data were entered into SPSS software (V 24). Data were demonstrated with frequency (percentage) or mean ± standard deviation. We used the Mann-Whitney test to compare the means of continuous variables. The Friedman test was used to compare the mean of variables over time in each of the 2 groups. The significance level in all analyses was considered at ˂0.05.

Results: ONSD after the termination of gas insufflation was significantly lower in the LPL group with the mean of 4.97±0.83 mm than the NPL group with the mean of 5.62±1.32 mm (p=0.018). ONSD before induction of anesthesia or immediately after gas insufflation did not differ significantly between LPL and NPL groups. Duration of anesthesia and surgery, mean arterial pressure, the total dose of propofol (p=0.600), and fentanyl (p=0.201) did not show significant differences between the 2 groups.

Conclusion: ONSD was lower with low-pressure laparoscopic cholecystectomy after the termination of gas insufflation, which emphasized the neural protective effect of low intraperitoneal pressure. Further studies are needed to evaluate this diagnostic tool in different populations, especially in patients with increased ICP undergoing laparoscopic interventions.

Comparison of pericapsular nerve group (PENG) block with fascia iliaca compartment block (FICB) for pain control in hip fractures: A double-blind prospective randomized controlled clinical trial

BACKGROUND

Fascia iliaca compartment block (FICB) is a common regional analgesic strategy in hip fracture surgery but, recently it has been suggested that FICB may not provide enough analgesia. Pericapsular nerve group block (PENG) is a novel method for hip analgesia which its efficacy is not well established yet. The aim of this study was to the effect of the PENG block in the control of the hip fracture pain as well as to compare the effectiveness of the PENG compared with FICB.

HYPOTHESIS

The hypothesis of this study was that the PENG block could be a good alternative to the FICB in hip fracture analgesia.

MATERIALS AND METHODS

This randomized controlled clinical trial was conducted in the Imam- Hossein Hospital, Tehran, Iran; between 2018 and 2019. Hip fracture patients were randomly divided into two groups; Group A (n=22) received FICB and Group B (n=30) received PENG block.

RESULTS

There was no significant difference between VAS score before blocks procedure between two groups (p=0.37). After 15minutes of blocks and after 12hours of post-surgery, VAS score significantly reduced in the PENG block group compared with the FICB group (p=0.031; p=0.021, respectively). The first time of the analgesic consumption after surgery was significantly longer in the PENG block compared with the FCIB (p=0.007). Compared with the FICB group, the total dose of morphine consumption during 24hours significantly reduced in the PENG block (p=0.008).

CONCLUSION

PENG block is a good method in hip fractures analgesia and provides better analgesia than FICB. However, further studies with larger sample sizes are required to validate the efficacy and superiority of the PENG blocks over conventional techniques.

LEVEL OF EVIDENCE

I.

Effect of Isolated Serum from Breast Cancer Patients with Pectoral Nerves Block on Breast Cancer Cell Line (MDA-MB-231) Apoptosis Index

Background

Breast cancer (BC) is the most frequent cause of cancer death in women. The thoracic pectoral nerve (PECS) block has been described as the gold standard analgesic modality for BC surgery. It has been previously reported that PECS is associated with decreased BC recurrence post-mastectomy. Although several anesthetic drugs and techniques are used in surgical oncology, their effects on the behavior of cancer cells are yet to be known and the key question of whether the anesthetic technique affects cancer outcome remains unresolved.

Objectives

Since anesthetic drugs and techniques and post-operative pain may affect BC recurrence, this study aimed to determine whether the anesthetic choice and technique, PECS II block, affects in vitro apoptosis of the MDA-MB-231 BC cell line.

Methods

Twenty-two female BC patients, 20 to 75-years-old, with the same pathologic grades were included in this study. The patients were randomly divided into two groups. The first group received propofol general anesthesia (PGA) associated with PECS and the second group received standard PGA. Blood was sampled pre and post-operation from all patients. The sera were isolated and then exposed to the MDA-MB-231 human BC cell line. The mean percentage of apoptosis indices was analyzed by flow cytometry using Annexin V-fluorescein isothiocyanate 24 hours after treatment with patients' sera.

Results

A significant decrease was seen in the mean viability percentage of BC cell line in the PECS group, besides a significant increase in the mean percentage of necrosis and late apoptosis indices compared to the control group after exposure to sera collected from patients post-operation. Intra-group analysis of the control group showed that the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of necrosis and late apoptosis index compared to pre-operation sera exposure. In the PECS group, the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of cell viability and late apoptosis index compared to pre-operation sera exposure.

Conclusions

In conclusion, anesthesia and BC surgery may induce apoptosis indices in the MDA-MB-231 human BC cell line. We also found that sera collected from PECS II block patients with BC could induce more apoptosis in the MDA-MB-231 cell line compared to collected sera from systemic analgesia alone after BC surgery.

Ultrasonographic Assessment of Metoclopramide Administration Effectiveness in Accelerating Gastric Emptying Before Urgent Surgery in Patients with Insufficient NPO Time

Background

Aspiration is one of the important complications of general anesthesia, although infrequent as well as accompanying high morbidity and mortality. The volume of gastric content is considered as a risk factor in this regard. Therefore, it is normally mostly recommend to consider proper fasting time before induction of general anesthesia.

Objectives

This study was conducted to assess the effect of metoclopramide on reducing gastric contents in patients with incomplete fasting before induction of general anesthesia.

Methods

This quasi-experimental study was conducted on patients with urgent surgical indications with incomplete NPO time. Every other patient received metoclopramide or placebo. Patients in the intervention group received 10 mg (2 ml) of intravenous metoclopramide, and patients in the control group received 2 ml of distilled water as a placebo. Patients in both groups underwent ultrasonography before starting surgery by an expert radiologist to calculate gastric antral grade (GAG) and cross-sectional antral area (CSA). These measurements were then taken for the second time 30 minutes after intervention, before starting the surgery. The values were compared statistically.

Results

The data of 60 patients were analyzed, of which 30 were in each group. The mean age, body mass index, type of the last consumed food (solid or fluid), NPO time in the two groups were not significantly different (P value > 0.05). The number of patients in the metoclopramide group with higher GAG (P value = 0.001) and the mean CSA (P value = 0.004) before the intervention was more than the control group. The GAG and mean CSA after intervention were not significantly different between the two groups; but the mean difference of decrease in CSA in the metoclopramide group was more than the control group (4.3 vs. 0.99; P value = 0.001), and changes of GAG after intervention to lower levels in the metoclopramide group was more than the control group (P value < 0.05).

Conclusions

In the current study in which ultrasonographic indexes, including GAG and CSA, were assessed as a suboptimal gastric emptying test method, it was found that metoclopramide could accelerate gastric emptying compared to placebo in patients with incomplete fasting before induction of general anesthesia.

Effect of Benson's Relaxation Technique on Propofol Consumption and Preoperative Anxiety of Patients Undergoing Cataract Surgery

Background

Benson’s relaxation (BR) technique is a suitable non-pharmacological approach to reduce preoperative anxiety (PA).

Objectives

This study aimed to investigate the effect of BR therapy on PA and the induction and maintenance dose of propofol during cataract surgery (CS).

Methods

Seventy-two patients were randomly divided into two experiments or BR and control groups. The Amsterdam and Spielberger State-Trait Anxiety inventory (STAI) scores were used to assess PA directly two days and a half-hour before the CS. The control group did not receive any preoperation intervention or relaxation. Benson’s relaxation method was performed three times, each time for 20 minutes, including two days before surgery, a night before surgery, and an hour before the surgery in the presence of a researcher by an audio file. The induction and maintenance dose of anesthetic drug was recorded and compared between the two groups.

Results

The mean propofol consumption was significantly reduced during the induction of anesthesia in the intervention group compared to the control group (0.99 ± 0.29 versus 1.29 ± 0.49; P = 0.005) as well as the maintenance of anesthesia (84.66 ± 17.98 versus 108.33 ± 34.38, P = 0.001). The results of the post-intervention Amsterdam anxiety score showed a significant decrease in the intervention group compared to the control group (P = 0.032, F = 9.61, Eta2 = 0.12). The control group showed a higher Spielberger state score compared to the intervention group as well as the Spielberger trait (P < 0.001, F = 14.78, Eta2 = 0.18).

Conclusions

The BR method effectively reduces the level of PA in patients undergoing CS. Moreover, it reduces the need for anesthetic drug, propofol, during surgery.

Maternal sciatic nerve administered bupivacaine induces hippocampal cell apoptosis in offspring

BACKGROUND

Bupivacaine, an amid-type local anesthetic, is widely used for clinical patients especially in pregnant women. In addition to neurotoxicity effect of bupivacaine, it can cross the placenta, accumulates in this tissue and retained in fetal tissues. Nevertheless, whether bupivacaine can cause neurotoxicity in fetus remains unclear. Hence, this study was design to investigate the effects of maternal bupivacaine use on fetus hippocampal cell apoptosis and the possible related mechanism.

METHODS

On day 15 of pregnancy, sciatic nerve of pregnant wistar rat (180-200 g) were exposed by lateral incision of the right thigh and 0.2 ml of bupivacaine was injected. After their delivery, we randomly selected one male offspring of every mother. On day 30 after of their birth, the rat's hippocampi were isolated for molecular studies. Western blotting was used to examine the expression of cleaved caspase-3, caspase-8 and p-Akt in fetal hippocampus.

RESULTS

Our results showed that maternal bupivacaine use caused a significant increment of cleaved caspase-3 and caspase-8 expression in fetal hippocampus compared with the sham group. In addition, maternally administered bupivacaine could significantly decrease hippocampal P.Akt/T.Akt ratio which was concurrent with an increment of cleaved caspase-3 and caspase-8 expression.

CONCLUSION

Our data suggest that maternal bupivacaine use increases fetal hippocampal cell apoptosis markers such as caspase 8 and cleaved caspase 3, at least in part, via inhibiting the Akt activation.

Low-Dose Fentanyl, Propofol, Midazolam, Ketamine and Lidocaine Combination vs. Regular Dose Propofol and Fentanyl Combination for Deep Sedation Induction; a Randomized Clinical Trial

INTRODUCTION

Need for procedural sedation and analgesia (PSA) is felt in emergency department (ED) more and more each day. This study aimed to compare the effectiveness of low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination with regular dose of propofol and fentanyl combination for induction of deep sedation.

METHODS

In this single-blind clinical trial, candidate patients for sedation and analgesia aged more than 15 and less than 60 years old, with pain score ≥6 were allocated to one of the groups using block randomization and were compared regarding onset of action, recovery time, and probable side effects.

RESULTS

125 patients with the mean age of 37.8 ± 14.3 years were randomly allocated to each group. 100% of the patients in group 1 (5 drugs) and 56.5% of the patients in group 2 (2 drugs) were deeply sedated in the 3^rd minute after injection. The 2 groups were significantly different regarding onset of action (p = 0.440), recovery time (p = 0.018), and treatment failure (p < 0.001).

CONCLUSION

Low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination was more successful in induction of deep sedation compared to regular dose of propofol and fentanyl combination. Recovery time was a little longer in this group and both groups were similar regarding drug side effects and effect on vital signs.

Developing Cervical Hematoma Following Jaw Thrust Maneuver Triggered Diagnosis of Neurofibromatosis: A Case Report and Brief Literature Review

A 25-year-old man underwent an excision of a thigh mass under general anesthesia without any complication. After the operation, he developed oxygen desaturation requiring a jaw thrust maneuver. A rapidly expanding hematoma on the right side of the neck was formed shortly after the application of the maneuver. The patient was returned to the operation room for a neck exploration. Damage to the facial artery and vein was noted. Further evaluations confirmed the diagnosis of Neurofibromatosis type 1 (NF-1). It is recommended that considering the probable risk of arising hematoma in NF-1 patients, application of jaw thrust maneuver should be performed meticulously.

The Effect of Perineural Administration of Dexmedetomidine on Narcotic Consumption and Pain Intensity in Patients Undergoing Femoral Shaft Fracture Surgery; A Randomized Single-Blind Clinical Trial

Dexmedetomidine is a selective α-2 adrenoceptor agonist with anxiolytic, sedative, and analgesic properties that prolongs analgesia and decreases opioid-related side effects when used in neuraxial and perineural areas as a local anesthetics adjuvant. The current study was designed to evaluate the effects of a single perineural administration of dexmedetomidine without local anesthetics on narcotic consumption and pain intensity in patients with femoral shaft fractures undergoing surgery. This prospective randomized single-blind clinical trial was conducted in patients undergoing femoral fracture shaft surgery. Based on block permuted randomization, the patients were randomly divided into intervention and control groups. The intervention group received 100µg dexmedetomidine, for a femoral nerve block without any local anesthetics. Total intraoperative opioid consumption, postoperative opioid consumption, visual analogue score (VAS) for pain, and hemodynamic parameters were recorded and compared. Finally the data from 60 patients with a mean age of 30.4±12.3 were analyzed (90% male). There were no significant differences between the baseline characteristics of the two groups (p>0.05). The mean total consumption of narcotics was reduced during induction and maintenance of anesthesia in the intervention group (p<0.05). The amount of postoperative narcotics required showed a significant difference in the intervention group compared with the control group (p<0.05). It is likely that perineural administration of dexmedetomidine significantly not only reduced intra and postoperative narcotic requirement but also decreased postoperative pain intensity in patients undergoing femoral shaft surgery. Femoral blockade by dexmedetomidine can provide excellent analgesia while minimizing the side-effects of opioids.

Intranasal Desmopressin Compared with Intravenous Ketorolac for Pain Management of Patients with Renal Colic Referring to the Emergency Department: A Randomized Clinical Trial

Background

This double-blind randomized clinical trial aimed at comparing the effect of intranasal desmopressin with that of intravenous ketorolac in pain management of patients with renal colic referring to the emergency department.

Methods

The patients were randomly divided to two groups. One group received intravenous ketorolac 30 mg and intranasal normal saline, while, the other one received intranasal desmopressin 40 μg and 1 mL of intravenous distilled water. The patients’ pain was evaluated using the visual analog scale at the time of admission, 10, 30, and 60 minutes after drug administration.

Results

Overall, 40 patients with mean age of 32.53 ± 6.91 participated in this study. Gender ratio (P = 0.288), mean age (P = 0.165), and mean pain score on arrival (P = 0.694) had no significant difference. The mean pain scores, 10, 30, and 60 minutes after drug administration in the ketorolac group was significantly lower than the desmopressin group, and decreased more rapidly (P < 0.001).

Conclusions

It is likely for desmopressin to be less efficacious than ketorolac, and desmopressin leads to a significant alleviation of pain in patients with renal colic.

Spontaneous Adrenal Hematoma in a Pregnant Woman; a Case Report

Spontaneous adrenal hematoma is a very rare condition and its prevalence has been reported to be about 1% in previous studies. Although various causes have been proposed to explain its incidence in existing case reports, the etiology and pathology of this condition is still not known. The present study presents a case of spontaneous adrenal hematoma in a pregnant 31 year old womanwithout history of trauma or other probable risk factors of hemorrhage, presenting to the emergency department with chief complaint of pain in the right flank.Diagnostic measures, imaging and laparotomy,confirmed the diagnosis of spontaneous adrenal hematomafor her.

Effect of dexmedetomidine infusion on N-terminal pro-B-type natriuretic peptide level in patients with femoral shaft fractures under general anesthesia

<p>This study was performed to assess the effect of dexmedetomidine on the level of N-terminal pro–B-type natriuretic peptide (NT-pro-BNP) in patients undergoing major orthopedic surgery. Patients undergoing general anesthesia for femoral shaft fracture surgery were randomly assigned to either 0.5 µg/kg/hour dexmedetomidine or normal saline. Changes in levels of NT-pro-BNP and hemodynamic parameters were compared. Data of 46 patients were analyzed and it was found that the change in NT-pro-BNP levels in the dexmedetomidine group was significantly less than the control group (p = 0.001). In addition, bleeding, changes in systolic and diastolic blood pressure in dexmedetomidine group was significantly less than the control group (p˂0.001). It is likely that dexmedetomidine infusion can reduce the rise of NT–pro-BNP level and therefore is associated with better cardiac outcome. In addition, dexmedetomidine infusion can achieve hemodynamic stability in femoral shaft fracture under general anesthesia.</p><p> </p>

Efficacy of measuring procalcitonin levels in determination of prognosis and early diagnosis of bacterial resistance in sepsis

Background:

Rapid and proper diagnosis of sepsis is one of the daily challenges of emergency department (ED) and intensive care units. The general aim of the present study was to determine the efficacy of measuring procalcitonin levels in the early diagnosis of bacterial resistance to antibiotics administered empirically in patients with sepsis.

Materials and Methods:

The present cross-sectional study consisted of patients with clinical evidence of sepsis or systemic inflammatory response syndrome (SIRS), referring to the ED of a third-level hospital in Tehran, Iran in 2012. After collection of basic and clinical data of patients, venous blood samples were taken for routine laboratory tests and determination of procalcitonin serum levels at baseline and 6 and 24 hours after administration of the first dose of an empirical antibiotic. The subjects were divided into two groups of discharged and expired and then comparisons were made using t-test, Chi-squared test and Fisher's test. Specificity and sensitivity of procalcitonin were evaluated along with ROC curve.

Results:

In the present study, 170 patients with sepsis were included. Evaluation of serum levels of procalcitonin 24 hours after administration of antibiotics exhibited the best sensitivity and specificity for each patient's response to antibiotics. Use of the cutoff point of 6.5 mg/mL for procalcitonin can predict the disease outcome with sensitivity and specificity of 67% and 80%, respectively.

Conclusion:

It is suggested that procalcitonin be used for the diagnosis of sepsis or SIRS resulting from an infectious disease, for follow-up of treatment and for evaluation of response to treatment.

Effects of dexmedetomidine versus ketorolac as local anesthetic adjuvants on the onset and duration of infraclavicular brachial plexus block

Background:

Infraclavicular brachial plexus block is an appropriate approach for distal arm and forearm surgeries. Local anesthetic adjuvant agents are used to improve the quality of nerve blocks. Dexmedetomidine and ketorolac are two different types of adjuvants, which have been used in some studies.

Objectives:

The purpose of this study was to examine the effects of dexmedetomidine and ketorolac as local anesthetic adjuvants on the onset and duration of infraclavicular brachial plexus block under ultrasound guide technique.

Patients and Methods:

In a clinical trial study, 111 ASA class I and II patients who were candidates for elective distal arm and forearm surgeries under ultrasound guided infraclavicular brachial plexus block divided into three 37 patient groups. In dexmedetomidine group, 25 mL of lidocaine 1.5% plus 4 ml of normal saline and 100 mcg of dexmedetomidine was injected. Ketorolac group received 25 mL of Lidocaine 1.5% plus 5 mL of ketorolac, and placebo group received 25 mL of lidocaine 1.5% plus 5 mL of normal saline as local anesthetic solution. Sensory and motor onset blocks, duration of sensory and motor blocks and first time to analgesic request and hemodynamic parameters were all recorded.

Results:

There were no significant differences in sensory block onset between three groups (P = 0.177). Motor block onset was statistically less in dexmedetomidine compared to ketorolac and placebo groups (both Ps < 0.001). Sensory block duration in dexmedetomidine group was significantly longer than ketorolac and placebo groups (both Ps < 0.001). Motor block duration in dexmedetomidine group was significantly longer than ketorolac and placebo groups (both Ps < 0.001). Time to first analgesic request after the procedures was longer in ketorolac compared to dexmedetomidine and placebo groups (P = 0.016, P < 0.001 respectively), but it was longer in dexmedetomidine compared to placebo group (P = 0.003). The differences of diastolic blood pressure in-between the 5th to 140th minutes after local anesthetic injection among the 3 groups were statistically significant and dexmedetomidine group shows the most reduction in diastolic blood pressure (P < 0.001). Dexmedetomidine showed the lowest mean arterial pressure (P = 0.016) and heart rate in dexmedetomidine group was significantly lower than ketorolac and placebo groups (P = 0.043).

Conclusions:

Our study showed that dexmedetomidine had better effects on sensory and motor block duration and motor block onset in comparison with ketorolac, as lidocaine adjuvants in infraclavicular brachial plexus block were present in both protocols. However, the first time to analgesic request by ketorolac was longer than dexmedetomidine.

Comparison of the effects of pre-anesthetic administration of normal saline, ringer and voluven on the spread of sensory block with hyperbaric bupivacaine spinal anesthesia

BACKGROUND

Spinal anesthesia is an important and commonly used method for surgical anesthetic in operating rooms. However, even with identical drug dosage and administration mode, the extent of drug distribution in vivo is highly variable and difficult to control. Preanesthetic administration of fluids immediately before spinal anesthesia (preload) is normal practice. The choice of fluid type may affect drug distribution as well as the duration and level of the block.

OBJECTIVES

We examined whether preloads of normal saline, Ringer, or hydroxyethyl starch has different effects on the time it takes to reach maximum block, and the distribution and duration of spinal block level.

PATIENTS AND METHODS

This was a randomized trial and the 150 patients selected were evenly divided into three groups and given; normal saline, Ringer, or hydroxyethyl starch 130/0.4f luids. Preload was given at 10 mL/kg for the normal saline and Ringer groups, and 5 mL/kg for the hydroxyethyl starch group, 10 min before the spinal anesthesia. Sensory block levels were recorded every 5 min until 30 min after spinal anesthesia and then at 60 and 90 min. Time taken to reach maximum and median sensory block, maximum and median level of block, duration of block, and hemodynamic status were recorded.

RESULTS

There were no statistically significant differences in the demographic characteristics between the three groups. Maximum block was higher in normal saline compared to Ringer (P = 0.029). Time taken to reach maximum block was greater in Ringer compared to both normal saline (P = 0.001) and hydroxyethyl starch (P = 0.003). Normal saline had a longer duration of sensory block T10 compared to Ringer and hydroxyethyl starch (P = 0.03).

CONCLUSIONS

Preload fluids have an impact on the level, distribution and duration of sensory block in spinal block. Of the three fluids, normal saline produced the greatest maximum and longest duration of block, whereas time taken to reach maximum block was longer in the Ringer group.

A case of death caused by tracheal tube aspiration

Introduction:

Airway management, especially outside the operating room, needs meticulous observation in order to avoid certain risks, such as; endotracheal tube (ETT) disloca­tion, esophageal intubation, and unwanted extubation. ETT or tracheostomy dislocation is responsible for one-half of death or brain damage cases in the ICU. Despite appropri­ate fixation of an ETT, the previously mentioned compli­cations can still occur . A broken ETT and consequent airway obstruction may lead to lethal complications.

Case Presentation:

We report a case of death caused by tracheal tube aspiration, where it was located distal to the vocal cords, with a part of it entering the right bronchus and the mediastinum, after tearing the right bronchus.

Discussion:

The vigilance and experience of medical personnel in the ICU, appropriate IV sedation, and using a bite block are the best ways to prevent mortality caused by aspiration of an ETT in all intubated patients.

Effects of clonidine premedication upon postoperative shivering and recovery time in patients with and without opium addiction after elective leg fracture surgeries

BACKGROUND

Opium is a highly addictive agent and the most common narcotic often misused in Iran. The pharmacokinetic of anesthetic drugs in patients with opium addiction is one of the great challenges for anesthesiologists. Hemodynamic instability and postoperative side effects are of these challenges which should be managed correctly.

OBJECTIVES

In this study we aimed to assess the effects of clonidine upon post anesthesia shivering and recovery time in patients with and without opium addiction after general anesthesia to decrease the subsequent complications related to the shivering and elongation of recovery time.

PATIENTS AND METHODS

In a randomized clinical trial, 160 patients candidates for elective leg fracture operations under general anesthesia were studied in four groups of 40 patients: Group 1 (placebo 1) were patients without addiction who got placebo 90 minutes before the operation. Group 2 (placebo 2) were patients with opium addiction which received placebo as group 1. Group 3 (Clonidine 1) patients without addiction who got clonidine 90 minutes before the operation and group 4 (Clonidine 2) who were opium addicted ones which received clonidine as premedication.

RESULTS

None of the patients with and without addiction in clonidine groups had shivering after the operation but in placebo groups shivering was observed and the difference between clonidine and placebo groups was statistically significant (P < 0.01). Recovery time in clonidine groups of patients with and without addiction was less than placebo ones (both P < 0.01) which the magnitude of difference was higher in opium addicted than non-addicted patients (P = 0.04).

CONCLUSIONS

Premedication with clonidine in patients with and without opium addiction can be effective to decrease the incidence of shivering and recovery time after operation.