Anesthesiology and Pain Medicine
Year:2011 | Volume:1 | Issue:2 (2)|Papers Count:20

Pain is a major public health issue throughout the world and represents a major clinical, social, and economic problem. The clinical, social, and economic costs of chronic pain in added health care costs, lost productivity, and lost income are significant, and if prolonged, it can cause distress, anxiety, and suffering. The burden that pain can place on individuals and the huge costs that society must bear as a result clearly indicate the need for collective thinking through a decision-making process. Acute pain is a major challenge worldwide, and chronic pain poses a massive disease burden, affecting an estimated 20% of adults, rising to 50% of the older population. In addition, cancer-related pain affects 70% of the 10 million cancer patients who are diagnosed annually, which is expected to double by 2020.

The term ‘probiotic’ is derived from the Greek/Latin word “pro” and the Greek word “bios, ” meaning “of life”.The concept of probiotics was first described by Metchnikoff in 1907. The World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations have defined probiotics as “live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host”. These agents are often administered concurrently with substances that promote bacterial colonization and growth (prebiotics); in this instance, they are referred to as synbiotics.

Background: Opioids, such as alfentanil, are used to facilitate endotracheal intubation without the use of neuromuscular blocking agents in patients undergoing elective surgery.Objectives: The goal of this study was to evaluate the endotracheal intubation conditions when remifentanil or alfentanil was used with propofol without the application of neuromuscular blocking agents.Patients and Methods: One hundred American Society of Anesthesiologists (ASA) grade I patients scheduled for elective surgery were enrolled in this prospective, randomized, triple-blinded study. The patients were randomized to group A (alfentanil) or R (remifentanil). In group A, alfentanil (50 mcg/kg) was intravenously injected over 10 seconds, and after 45 seconds or at the occurrence of apnea, propofol (2 mg/kg) was intravenously injected over 5 seconds. Thirty seconds after the administration of propofol, laryngoscopy and endotracheal intubation were attempted. In group R, remifentanil (5 mcg/kg) was administered instead of alfentanil. Intubation conditions, including ease of laryngoscopy, patency of the vocal cords, jaw relaxation, limb movement (1-4 score), and also, demographic data were evaluated.Results: There were no demographic data differerences between groups (age, weight, and sex). Further, laryngoscopy, jaw relaxation, and limb movement scores were similar in the R and A groups and there were no significant differences, but vocal cords were significantly more patent in group R than those in group A (P=0.028).Conclusions: The results of this study showed that remifentanil, similar to alfentanil, provided excellent conditions for endotracheal intubation when used with propofol for the induction of anesthesia; however, remifentanil improved the patency of the vocal cords to a greater extent than alfentanil.

Background: Post-dural puncture headache (PDPH) is an iatrogenic complication of spinal anesthesia. Reported risk factors for PDPH include sex, age, pregnancy, needle tip shape and size, bevel orientation, approach and others. Little is known regarding the effect of different approaches on the incidence of PDPH.Objectives: In this study we aimed to compare the incidence of PDPH in the case of median and paramedian approaches in patients undergoing spinal anesthesia for orthopedic operations.Patients and Methods: Patients scheduled for orthopedic surgery under spinal anesthesia between 2007 and 2008 were studied in a double-blinded randomized controlled trial. The patients were randomized to receive spinal anesthesia by either a median (n =75) or paramedian (n=75) approach through a 25-gauge Crawford needle. No premedication was given, and all patients received 500 mL of normal saline intravenously and 4 mL of 0.5% isobaric Marcaine 30 minutes prior to surgery in both approaches.Results: Fifteen patients (10%) developed PDPH. There was no significant difference in the incidence of PDPH in both groups, with 7 (9.3%) patients in the median approach group versus 8 (10.7%) in the paramedian approach group developing typical PDPH (P =0.875). However, a significant difference in PDPH incidence (P=0.041) was observed between females (9; 16.7%) and males (6; 6.3%).Conclusions: There is no difference between median and paramedian approaches with respect to PDPH incidence; the paramedian approach is therefore recommended, especially for older patients with degenerative changes in the spine and intervertebral spaces and those who cannot take the proper position. Moreover, the rate of PDPH was found to be significantly higher in females than in males.

Background: Trigeminal neuralgia (TN) is neuropathic pain which can involve any part or side of the face.Objectives: The objectives of this study were to find the most common branch of trigeminal nerve affected and the most common side involved.Patients and Methods: This Cross sectional study was carried out on 100 patients of trigeminal neuralgia in one year time. The diagnosis was based on a detailed history, clinical examination and control of pain by carbamazepine being taken supplemented by radiographic investigations. The collected data was analysed by SPSS 16.Results: The age of the patients varied from 40 to 80 years with a mean age 54 years at the time of presentation. The males to females ratio was 1: 2. The right side of the face was found to be involved in seventy patients (64 %) and left side in (36 %). No case presented with bilateral involvement. The Mandibular division was most commonly involved in this study (n=55; 55%) and least was ophthalmic divisions (n=6; 6%).Conclusions: This study demonstrated numerous clinical similarities of trigeminal neuralgia afflicting different populations. Right side was more involved along with mandibular division the most commonly affected. However studies needs to be done to know the exact reasons of involvement of the affected side and branches.

Background: Back pain is one of the most common health problems for which physicians are consulted, and it can considerably decrease the quality of life of patients during a great part of their lives.Objectives: Our study was designed for assessing the improvement in the quality of life of patients undergoing lumbar discectomy for chronic low back pain.Patients and Methods: We included 148 patients with chronic low back pain in the analytic observational study. Using the 36-Item Short-Form Health Survey (SF-36), we evaluated the quality of life before and 6 and 12 months after lumbar discectomy.Results: Physical and mental health scores of patients significantly improved after 6 and 12 months of lumbar discectomy. The mean improvement in physical health scores was significantly higher in female patients than in male patients. However, the improvement in mental health scores was not significantly difference between the 2 sexes and the educational and body mass index (BMI) groups.Conclusions: Lumbar discectomy improves both the physical and mental health subscale of the quality of life in patients with chronic disc herniation.

Background: Low back pain is a major cause of disability and can result in substantial morbidity and high healthcare costs. Botulinum toxin has been used successfully to alleviate pain for a number of conditions caused by muscle contractions or spasms.Objectives: The aim of this study was to investigate the efficacy of botulinum toxin type A (BoNT-A; Dysport®, Ipsen, UK) for treating chronic low back pain (CLBP).Patients and Methods: This was a single-blind, randomized clinical trial study. Fifty patients with CLBP received either BoNT-A (40 Ipsen units per injection) or saline in 5 sites in the paraspinal muscles (n=25 per group). A visual analogue system (VAS) was used to measure pain levels at baseline and at 4 and 8 weeks post-injection. Disability was assessed using the Oswestry low back pain disability questionnaire at baseline and at 8 weeks post-injection.Results: After 4 weeks, 76% of patients in the BoNT-A group reported pain relief compared to 20% in the saline group (P<0.005). Additionally, greater pain relief was experienced by patients in the BoNT-A group at 8 weeks (64% vs.12%; P<0.001). By week 8, significant functional improvement (a minimum two-grade improvement between baseline and post-treatment assessments) was demonstrated in a higher number of patients receiving BoNT-A than in the saline group (68% vs.12%, respectively; P<0.005). Patients experienced only minor side effects.Conclusions: BoNT-A improves CLBP with a low incidence of side effects and can be used as a therapeutic tool in the management of these patients.

Background: The pressor response to laryngoscopy is known to be exaggerated in patients with severe preeclampsia.Objectives: The aim of the present study was to compare the efficacies of continuous intravenous (IV) infusion of nitroglycerine, IV hydralazine, or sublingual nifedipine in modifying cardiovascular responses to endotracheal intubation, in women with severe preeclampsia undergoing cesarean delivery under general anesthesia.Patients and Methods: A total of 120 patients undergoing cesarean delivery were randomly divided into 3 groups, each receiving one of the following drugs before intubation: 5 μg/min nitroglycerine administered by continuous IV infusion (Group NTG, n= 40); a 10-mg capsule of nifedipine deposited sublingually (Group NIF, n=40); or 5–0 mg hydralazine intravenously (Group H, n=40). Heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP) were simultaneously recorded in the mother at pre-induction, pre-intubation, and at 1, 3, 5, and 10 min after intubation.Results: In contrast to those in group NIF and group H, the patients in group NTG showed no significant increases in HR, SAP, DAP, or MAP after intubation, compared to baseline. The incidence of hypotension was significantly greater in group NIF than in group H or group NTG [15 (37.5%) vs.8 (20%) vs.5 (12.5%) respectively, P=0.025].Conclusions: In patients with severe preeclampsia undergoing cesarean delivery, a continuous IV infusion of nitroglycerine was able to attenuate the cardiovascular response to intubation to a greater extent than the use of sublingual nifedipine or IV hydralazine, without significant adverse effects on the newborn.

Background: Measures of mental workload are now commonly used in industries to identify sources of error and to improve performance.Objectives: This study aimed to review the evidence for the use of this technique within medicine.Patients and Methods: We used search engines and the internet to identify experimental studies that included a measure of mental workload in medical practitioners or trainees/students. Studies that aimed to measure mental “stress” as a disorder, or “productivity” were excluded. Each abstract and then the full paper were appraised prior to inclusion.Results: Thirty-three studies were identified that matched the inclusion criteria. Although these covered a variety of settings, common methods were identifiable. The results support the concept of mental workload measurement as an important factor in medical performance.Conclusions: The limited number of studies and the variety of definitions and measurement techniques used in these studies, make direct comparisons difficult. However, the utility of this methodology in medical education appears to have been established, and guidelines for further research methods are proposed.

Throughout the history of medicine, various drugs and technologies have been developed, and these developments have tremendously contributed to a range of treatments that are now taken for granted. It is only when we take time to study the development of these important drugs and technologies that we really realize how much effort and dedication went into developing them. Cocaine is an example of a drug that had many contributors aiding its use in medicine. Here, I discuss the factors and people that have contributed to the successful use of cocaine in anesthesia.Cocaine is an ancestor of modern-day anesthetics, although some perceive it as a drug associated with the dark and damaged segment of our society.

We read with great interest the recent article by Farzanegan et al. regarding the effect of lumbar discectomy on disability and depression in patients with chronic low back pain . Pain and depression create a vicious cycle in which pain worsens the symptoms of depression, and then the resultant depression further worsens the feeling of pain. The authors maintain that lumbar discectomy breaks this cycle, which is indeed an interesting possibility. However, it is unclear whether or not patients with a family history of depression and those on antidepressants were excluded from the study.

The recent article by Farzaneganet al. on the effects of lumbar discectomy on the rates of disability and depression among patients with chronic low back pain is interesting (1). Their study suggests that among patients with more than 3 months of back pain due to a herniated disc, surgical treatment (particularly laminectomydiscectomy) can improve both disability and depression.Their paper highlights 2 important points: first, chronic pain conditions can lead to increased disability and depression, and, second, successful treatment of these conditions can improve the patients’ disability and depression.

Evidently disc surgery patients are at higher risk of suffering from depression and anxiety than the general population. The authors have concluded that the depression and disability scores of patients with chronic herniated discs before lumbar discectomy significantly decreased after surgery. It has long been known that patients with psychological comorbidities often incur long-term disability from low-back pain.

Acute pain management in opioid dependent patients remains a challenging and complex problem and it is becoming more common. In the acute pain setting, in addition to their daily opioid maintenance these patients need a multimodal approach. Imaniet al. in their study have shown that instead of simply increasing the dosage of morphine, using morphine in addition to chlorpromazine, promethazine, midazolam and clonidine significantly controlled pain scores and increased patient satisfaction without having notable side effects.

I read with interest the article by Farzaneganet al., titled “Effects of lumbar discectomy on disability and depression in patients with chronic low back pain”. It was a very well-written article on an important subject, which has remained largely ignored. I would therefore like to congratulate the investigators for highlighting the subject. However, I have a few concerns regarding the methodology of the study. First, I am not convinced that discectomy or laminectomy is ever indicated for back pain alone. It is also unclear whether these operations can lessen chronic back pain; they could also aggravate the pain. The best surgical outcomes after discectomy or laminectomy are expected in cases of radicular leg pain that is unresponsive to the best medical management available.

With great interest I have read an excellent article “Evaluation of the efficacy of intrathecal injection of amitriptyline and doxepin in spinal anesthesia in comparison with bupivacaine in rats“, published in your respected journal.The authors present and elaborate a very interesting subject of the application of tricyclic antidepressants as a local anesthetic. I totally agree with the authors of article that claim that there is a tendency of intrathecal injection of various drugs with different effect mechanisms. Several papers in the recent years, including the already mentioned article, indicate the local anesthetic effect of tricyclic antidepressants. In doing so, they demonstrate the effect of the drug on motor, sensory and proprioceptive fibers.

Alleviation of back pain and/or any disability due to pain in patients with lumbar disc disease undoubtedly gives a sense of relief and well being. The use of noninvasive or minimally invasive interventional procedures for this condition is basically aimed at limiting pain and disability.A number of such minimally invasive percutaneous techniques for the treatment of lumbar disc disease have been developed over the years, with the common tenet being the ability to act directly on the disc content without violating the spinal channel or increasing subsequent risk of scarring.

I read the article entitled “The Maternal and Neonatal Effects of Adding Tramadol to 2% Lidocaine in Epidural Anesthesia for Cesarean Section”. The authors demonstrated that tramadol 50 mg or 100 mg associated to lidocaine is appropriate for this surgery and also improve sensory and motor blockade effects without any increase in complications.However some important reflections and some missing data may be consider for full understanding of the article. For instance, one question came to my mind during the analysis-why haven’t the article focused on tramadol applied on spinal anesthesia? Neuraxial anesthesia is undoubtedly the most appropriate technique for elective cesarean delivery since the relative risk of mortality from general versus regional anesthesia is 16.7.

My objective was to explore and analyze the influence of depression on the change in disability index in patients undergoing lumbar spine surgery on the basis of a work presented by Farzanegan, et al. .It is well known in the pain and psychiatric literature that chronic low back pain (LBP) is commonly associated with depression and disability. However it is not well understood if the pain is accompanied by depression (secondary or reactive depression) or the pain is a consequence of depression (primary depression). It is assumed that about between 20% and 45% of patients with chronic pain are diagnosed to be depressed.

I read with a great interest the recent article by Alebouyeh et al. about intrathecal administration of amitriptyline and doxepin to induce spinal blockade and comparison of their effects with those of bupivacaine.