Anesthesiology and Pain Medicine
Year:2021 | Volume:11 | Issue:6|Papers Count:14

Background: The coronavirus disease 2019 (COVID-19) has a high prevalence and mortality worldwide. Thousands of patients with acute respiratory failure caused by COVID-19 are daily hospitalized in intensive care units (ICUs) around the world. Many of these patients require full mechanical respiratory support and long-term ventilator use. Using diff erent ventilators and calculating important variables can be helpful in meeting therapeutic needs of patients. Objectives: The aim of present study was to investigate the eff ect of expiratory time constant (RCEXP) on the course of treatment and duration of mechanical ventilation in patients with acute respiratory failure hospitalized in ICU. Methods: The present cross-sectional study was conducted on 60 patients with acute respiratory failure who were hospitalized in the ICU and underwent mechanical ventilation due to COVID-19 in the fi rst six months of 2020. The variables of RCEXP, lung compliance and lung resistance in all patients were recorded daily and analyzed. Then, based on clinical outcome, the patients were divided into two groups: the patients with wean outcome (N = 40) and those with death outcome (N = 20). Results: The mean  SD of lung compliance in patients who were separated from ventilator and patients with death outcome were 74. 73 (18. 58) mL/cm H2O and 36. 92 (10. 56) mL/cm H2O, respectively, which was statistically signifi cant (P = 0. 001). The mean  SD of lung resistance in patients who were separated from ventilator and patients with death outcome were calculated at 9. 25 (4. 62) and 14 (6. 5), respectively, which was statistically signifi cant (P = 0. 015). Also, there was a statistically signifi cant diff erence between the two groups in terms of mean  SD of RCEXP (0. 67 (0. 23) vs. 0. 49 (0. 19), P = 0. 010). Conclusions: According to the results of this study, there was a signifi cant diff erence between high resistance, low compliance, RCEXP, and weaning success of intubation in patients hospitalized in the ICU.

Neuropathic pain is a challenge for physicians to treat and often requires a multimodal approach with both pharmacologic and lifestyle interventions. Mirogabalin, a potent, selective ligand of the  2-1 and  2-2 subunits of voltage-gated calcium channels (VGCCs), provides analgesia by inhibiting neurotransmitter release at the presynaptic end of the neuron. Mirogabalin off ers more sustained analgesia than its gabapentinoid counterparts in addition to a wider safety margin for adverse events. Recent clinical trials of mirogabalin have demonstrated both effi cacy and tolerability of the drug for the treatment of diabetic peripheral neuropathic pain and postherpetic neuralgia, leading to its approval in Japan. While still not yet FDA approved, mirogabalin is still in its infancy and off ers potential into the treatment of neuropathic pain and its associated comorbidities.

Background: Hyperglycemia during coronary artery bypass graft surgery (CABG) strongly predicts intra-and post-operative adverse consequences. Objectives: This study aimed to evaluate the quality of glycemic management during CABG in an academic center regarding peripheral blood and coronary sinus values. Methods: This prospective descriptive study encompassed 55 eligible patients undergoing on-pump CABG surgery in 2020. Peripheral blood glucose (BG) was measured four times, before anesthesia induction (T0), before cardiopulmonary bypass pump (CPB) (T1), during CPB (T2), at the end of CPB (T3), and at the end of surgery (T4). The surgeon also took a sample of the coronary sinus BG. Results: The BG variations from T0 to T4 were statistically signifi cant (P < 0. 0001). The higher values detected in the ASA class III compared to ASA classes II were statistically signifi cant at T1 (P = 0. 01) and T2 (P = 0. 025): patients with the higher BMI showed the higher levels of BG. In this regard, the diff erences were signifi cant at T0 (P = 0. 0001), T2 (P = 0. 004), and T3 (P = 0. 015). Regarding coronary sinus, the mean BG was 222. 18  75. 74 mg/dL. It was also observed that the ASA class III (P = 0. 001), longer duration of CPB (P = 0. 021), higher IV fl uid volume administrated during surgery (P = 0. 023), higher BMI (P = 0. 0001), and less urine volume at the end of surgery (P = 0. 049) were signifi cantly associated with the higher BG of the coronary sinus. Conclusions: The existing glycemic management protocols on the CABG patients were acceptable in our hospital. However, the BG level of the coronary sinus was higher than the peripheral one.

Following the broad spread of SARS-CoV-2 in Wuhan City from December 2019, the World Health Organization (WHO) declared the novel coronavirus disease (COVID-19) a public health emergency of international concern; by 11 March 2020, the COVID-19 outbreak was declared a global pandemic (1, 2). Until now, no specifi c therapies have yet been developed to prevent or reduce the risk of developing complications and organ dysfunction of COVID-19 (3). Therefore, early and accurate identifi cation of patients at higher risk of developing severe disease is so crucial (4) both as part of guidance for clinical treatment and resource allocation as well as to highlight the likely groups benefi ting from novel disease-modifying therapies...

Background: Paravertebral blocks are one of the possible postoperative pain management modalities after laparotomy. Adjuvants to local anesthetics, including alpha agonists, have been shown to lead to better pain relief and increased duration of analgesia. Objectives: The aim of this study is to examine the eff ect of adding dexmedetomidine to bupivacaine for ultrasound-guided paravertebral blocks in laparotomy. Methods: In this double-blind, randomized controlled trial (RCT), we enrolled 42 patients scheduled for T6 to T8 thoracic paravertebral block (TPVB) for analgesia after laparotomy. The patients were randomly assigned into two groups of BD (bupivacaine 2. 5 mg/mL 20 mL plus dexmedetomidine 100  g) and B (bupivacaine 20 mL alone). Following surgery, intravenous fentanyl patientcontrolled analgesia was initiated. The numerical rating scale (NRS) for pain, sedation score, total analgesic consumption, time to fi rst analgesic requirement, side eff ects (such as nausea and vomiting), respiratory depression, and patients’ satisfaction during the fi rst 48 hours of evaluation were compared in the two groups. Results: Pain scores and mean total analgesic consumption at the fi rst 48 hours in the BD group were signifi cantly lower than Group B (P = 0. 03 and P < 0. 001, respectively). The time of fi rst analgesic request was signifi cantly longer in BD group (P < 0. 001). Sedation scores and side eff ects did not diff er signifi cantly between the two groups. Conclusions: Adding dexmedetomidine to bupivacaine for TPVB after laparotomy yielded better postoperative pain management without signifi cant complications.

Rodent behavior assessments have been developed to evaluate pain. However, their fi dgety activity and reactivity to human contact make it hard to activate animals in a consistent manner and get uniform and trustworthy responses. The present study was performed on prairie voles (aged 8 weeks). Sham (7 male prairie voles) and chronic constriction injury (CCI) (8 male prairie voles) rodents were investigated before surgery and four and seven days later. Each animal was assessed for nociceptive behavior. Pressure and mechanical threshold tests were conducted by the application of three diff erent pushers to the center of hind paws and arterial clips to the toes while sedated with isofl urane. The CCI aff ected right lower extremity prominently increased nociceptive behavior scores four and seven days after the experiment, and the CCI aff ected right hind paw prominently decreased pressure and mechanical threshold tests four and seven days after the experiment. The pressure and mechanical thresholds were relevant to the scorings of nociceptive behavior in CCI model animals.

Background: Thoracotomy is one of the most painful surgeries, and failure to alleviate patients’ pain can have dangerous consequences. Objectives: This study aimed to evaluate the addition of dexmedetomidine to ropivacaine in the intercostal block for postoperative pain control in patients undergoing thoracotomy. Methods: In this randomized clinical trial, 74 patients aged 18 to 60 years with ASA class I or II, BMI less than 40, and no severe systemic problems referred to a teaching hospital in Ahvaz to undergo thoracotomy were included in the study and randomly divided into two groups. After surgery, an ultrasound-guided intercostal block was done with ropivacaine (5 cc of 0. 25% solution; group R) or ropivacaine (5 cc of 0. 25% solution) plus dexmedetomidine (0. 5  g/kg; group RD) per dermatome. Two dermatomes above and two dermatomes below the level of surgical incision were used. Pain, total opioid consumption, length of ICU stays, time to fi rst rescue analgesic, and time to get out of bed were compared between the two groups. Results: The intercostal block signifi cantly reduced pain in both groups (P < 0. 0001). The pain was lower in the RD group than in the R group from six hours after the intervention up to 24 hours after (P < 0. 001). The number of patients who needed rescue analgesia at 12 hours was signifi cantly lower in the RD group (P < 0. 05). The RD group also had lower total opioid consumption and a longer time to receive the fi rst rescue analgesia (P < 0. 01). There was no signifi cant diff erence between the two groups in the length of hospitalization and the time to get out of bed. Conclusions: Dexmedetomidine is an eff ective and safe choice to be used as an adjunct to ropivacaine in ICB, and it extends the duration of analgesia in combination with ropivacaine after thoracotomy.

Background: Acute postoperative pain is a signifi cant cause of morbidities. This study aimed to evaluate the eff ect of intraoperative blood pressure during laparoscopic cholecystectomy under general anesthesia on postoperative pain in patients without underlying disorders. Methods: In this randomized clinical trial, 72 patients undergoing general anesthesia for elective laparoscopic cholecystectomy were randomly assigned into two groups: Group A with higher than baseline preoperative blood pressure (MAP allowed to increase up to 20% higher than baseline MAP by inducing pneumoperitoneum) and group B with normal to low blood pressure (MAP deliberately controlled at a tight limit from normal baseline MAP values to 20% less than baseline by titrating TNG infusion). The Visual Analog Scale (VAS) after 2, 8, 12, and 24 hours of surgery, and the total dose of meperidine used to manage postoperative pain were recorded and compared between the two groups. Results: The pain scores in group A were signifi cantly lower than group B (P = 0. 001). The postoperative analgesia request time was diff erent between the two groups (P = 0. 53). During the fi rst 24 hours, the total meperidine consumption dose in group A was signifi cantly lower than in group B (P = 0. 001). Conclusions: High intraoperative blood pressure may aff ect the postoperative pain after laparoscopic cholecystectomy and lead to less postoperative pain score and analgesic requirements.

Due to the COVID-19 pandemic, the demand for blood products may decrease as the health care system shifts toward treating the increased number of patients affl icted with COVID-19 and delaying selective surgeries and emergency procedures. One of the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks. This happens due to the limitations of attendance of donors in blood centers, lack of awareness, misinformation, fear of being infected while donating blood, and restricting the freedom of blood collection teams to attend public places. Blood transfusion services should be prepared and well-responded in a timely manner. In this regard, appropriate use of blood, diminishing unnecessary transfusions, and implementation of patient blood management (PBM) principles are considered as signifi cant measurements. PBM can help maintain blood supply throughout the crisis and reduce the pressure on blood demand. As a result, blood products can be saved for patients who need it urgently. PBM focuses on the patient, as well as the conditions that make patients transfuse blood, such as blood loss, coagulopathy, platelet dysfunction, and anemia. Thus, the majority of health systems in diff erent countries have made recommendations to the PBM in hospitals.

Background: Dilatation and curettage (D & C) is one of the relatively common surgeries among women. Familiarity with the analgesics, along with their diff erent uses and specifi c characteristics, can help to determine the best and most appropriate drug to control pain in the patients. Objectives: This study aimed to compare the eff ects of ketofol, dexmedetomidine, and isofol in anesthesia of candidates for D & C. Methods: In this double-blind clinical trial, 150 candidates for D & C surgeries with ASA class 1 and 2 were included. Patients were randomly divided into three groups. The fi rst group received ketamine + propofol, the second group received dexmedetomidine, and the third group received isofol (isofl urane + propofol). Any hemodynamic changes or respiratory disorders, including apnea or hypoventilation, drop in the level of blood oxygen saturation, and the need for respiratory support, were recorded and compared. Results: Hypoventilation was observed in 47 patients in isofol group, 18 in the dexmedetomidine group, and 42 in ketofol group. Also, 48 patients in the isofol group, eight in the dexmedetomidine group, and 33 in the ketofol group experienced apnea. Moreover, 17 patients in the dexmedetomidine group, 35 in the ketofol group, and eight in the isofol group experienced bradycardia. The rate of bradycardia was signifi cantly higher in the dexmedetomidine group (70%) compared to the other two groups, and the rate of hypotension was signifi cantly higher in the isofol group (P = 0. 001). Conclusions: According to the results, dexmedetomidine was associated with fewer complications during general anesthesia in D & C surgery.

Background: Tracheal intubation is the most reliable way of securing an airway. Pediatric airway management is one of the signifi cant challenges, especially for non-pediatric anesthesiologists. Early airway evaluation for detecting diffi cult intubation and preventing catastrophic events is necessary before anesthesia, especially in children. Objectives: Therefore, this study was done to compare some valuable adult predictors in children under two years of age. Methods: This prospective descriptive-analytical study was performed on 405 children under two years of age that were referred for elective surgery under general anesthesia with endotracheal intubation in Imam Hossein Hospital, Isfahan. Under sedation in a supine position, we measured items, including age, weight, height, stern omental distance (SMD), mouth opening (MO), neck circumference (NC), acromio-axillo-suprasternal notch index (AASI), and intubation diffi culty scale score (IDS). An expert anesthesiologist did laryngoscopy and intubation, and diffi cult cases were recorded. Results: Our study showed that the frequency of diffi cult intubation with IDS > 4 was %16, and with IDS > 5 was %3. The variables, including age, weight, height, and SMD, signifi cantly predicted diffi cult intubation. The cut-off points for age < 6 months, weight < 5/9 kg, height < 61 cm, and SMD < 5/3 cm were obtained, respectively. Other variables, such as MO, AASI, NC, and sex, were unreliable predictors for diffi cult intubation. Conclusions: We found that IDS > 4, age< 6-month, weight < 5/9 kg, and SMD < 5/3 cm are predictors for diffi cult intubation. It is helpful for the anesthesiologist to measure these predictions before anesthesia is started to fi nd who has diffi cult intubation.

Background: Postoperative pain following laparoscopic cholecystectomy (LC) arises from incision sites and residual intraperitoneal CO2 gas. Opioids as a class of pain-relieving drugs are broadly used to control pain after LC; however, these drugs can cause various side eff ects. Objectives: The purpose of this study was to compare the effi cacy of intraperitoneal injection of bupivacaine with that of intravenous ketorolac in managing postoperative pain in patients who had undergone LC. Methods: This randomized, double-blind clinical trial was carried out on patients who had undergone LC. Ninety patients who had undergone elective LC were randomly divided into 3 groups (n = 30 for each group). Group A received 40 mL of 0. 25% bupivacaine solution intraperitoneally at the end of the operation; group B received 30 mg of ketorolac intravenously 30 minutes before surgery and every 8 hours after surgery, and patients in group C received normal saline intraperitoneally and intravenous injection. The patients were postoperatively assessed for Visual Analog Scale (VAS) scores, postoperative opioid consumption, shoulder pain, side eff ects (sedation, nausea, and vomiting), and satisfaction. The data were analyzed using SPSS. P values < 0. 05 were considered signifi cant. Results: The intraperitoneal injection of bupivacaine and intravenous injection of ketorolac were signifi cantly eff ective in reducing postoperative abdominal pain, shoulder pain, and incidence of nausea and vomiting compared to the placebo group (P < 0. 001). Although intraperitoneal bupivacaine and intravenous ketorolac had no signifi cant diff erence in pain relief compared with each other, patients in both bupivacaine and ketorolac groups were signifi cantly more satisfi ed with their analgesia compared to the control group (P < 0. 001). Conclusions: Intraperitoneal injection of bupivacaine and intravenous injection of ketorolac both are safe and eff ective methods to control pain, nausea, and vomiting after LC.

Background: Airway protection during anesthesia is often the primary concern of anesthetists when working with obese patients and always is a diffi cult task due to increased exposure to harmful eff ects of apnea, hypoxia, and impaired respiratory mechanics. Objectives: The primary goal of this research was to determine the diagnostic accuracy of combined Mallampati and Wilson score in detecting diffi cult intubation in obese patients undergoing surgery by taking the Cormack-Lehane grading on direct laryngoscopy and intubation as the gold standard. Methods: This descriptive cross-sectional study was done in 300 obese patients with BMI > 29. 9 kg/m. Modifi ed Mallampati and Wilson score was recorded preoperatively for each patient in the sitting position by the primary investigator. Endotracheal intubation grades were also recorded, and grades IIb, III, and IV were regarded as diffi cult intubation according to the Cormack-Lehane intubation classifi cation. Results: The mean age was 46. 76  15. 57 years. The sensitivity, specifi city, positive predictive value, negative predictive value, and diagnostic accuracy of the combined Mallampati and Wilson score for detecting diffi cult laryngoscopy and diffi cult intubation were 75. 0, 98. 8, 92. 9, 95. 0, and 94. 6%, respectively. Conclusions: Combined Mallampatti and Wilson score is highly accurate in the initial diagnostic workup of obese patients at risk of diffi cult intubation. It is easy to calculate and lower the risk of intubation-related complications and failure.

Pain, the most common symptom reported among patients in the primary care setting, is complex to manage. Opioids are among the most potent analgesics agents for managing pain. Since the mid-1990s, the number of opioid prescriptions for the management of chronic non-cancer pain (CNCP) has increased by more than 400%, and this increased availability has signifi cantly contributed to opioid diversion, overdose, tolerance, dependence, and addiction. Despite the questionable eff ectiveness of opioids in managing CNCP and their high rates of side eff ects, the absence of available alternative medications and their clinical limitations and slower onset of action has led to an overreliance on opioids. Conolidine is an indole alkaloid derived from the bark of the tropical fl owering shrub Tabernaemontana divaricate used in traditional Chinese, Ayurvedic, and Thai medicine. Conolidine could represent the beginning of a new era of chronic pain management. It is now being investigated for its eff ects on the atypical chemokine receptor (ACK3). In a rat model, it was found that a competitor molecule binding to ACKR3 resulted in inhibition of ACKR3’ s inhibitory activity, causing an overall increase in opiate receptor activity. Although the identifi cation of conolidine as a potential novel analgesic agent provides an additional avenue to address the opioid crisis and manage CNCP, further studies are necessary to understand its mechanism of action and utility and effi cacy in managing CNCP.