Anesthesiology and Pain Medicine
Year:2011 | Volume:1 | Issue:1 (1)|Papers Count:8

The practice of modern anesthesiology has been developed from intraoperative period into perioperative period. Postoperative pain management is one of the most important components of adequate post-surgical patients care. This article wrote with the aim of emphasis on importance and effectiveness of post-operative pain management. Reading this article is beneficial for physicians, interventional pain managers and who care about pain medicine. Unrelieved acute pain after surgery usually elicits pathophysiologic neural alterations, including not only peripheral but also central sensitization which evolves into chronic pain syndromes. The main purpose of perioperative pain control is providing an adequate comfort level and acceptable side effects for patients. Effective postoperative analgesia improves patients’ outcome as observed by early ambulation, decrease in side effects, and reduce the incidence of postoperative chronic pain (1-3).

A number of decades have passed since the beginning of clinical use of clonidine. Nowadays, there is growing role defined for clonidine, an alpha-2 adrenergic agonist, used originally as an antihypertensive drug and then, as an oral, intravenous or now, an intrathecal agent.This drug would surpass the blood-brain barrier to target the central alpha 2 adrenoceptors to affect the CNS by decreasing the brain sympathetic tone; this would result in decreased systolic and diastolic blood pressure and heart rate. However, central alpha 2 adrenoceptor agonistic effects is not the only route for clonidine, because the drug has intrathecal effects when administered as an adjuvant during spinal or epidural anesthesia (combined with local anesthetics). Besides, its peripheral effects have been described fully. There are a number of studies well demonstrating that oral clonidine as a pretreatment to anesthesia, can increase the quality of perioperative sedation and analgesia while having just a few side effects.

Background: Addicted patients present difficulties for pain management because they have another problem besides their pain. Adding adjuvants to opioid pumps to intensify quality, control other problems, lengthen analgesia, and reduce side effects has been considered in the field.Objectives: The objective of this study was to evaluate the analgesic effects of adding clonidine, promethazine, chlorpromazine, and midazolam to morphine in patientcontrolled intravenous analgesia (PCIA) in orthopedic patients with addiction problems.Patients and Methods: 90 patients with histories of substance abuse were enrolled in this randomized controlled trial. Patients were randomly divided into three groups.The first group received 20 mg of morphine sulfate plus 50 mg of chlorpromazineplus 50 mg of promethazine plus 10 mg of midazolam (M20P). The second group received the first group’s regimen plus 150 micrograms of clonidine (M20PC). The third group received 40 mg of morphine sulfate (M40). A pump with a flow rate of 5 mL/h was chosen. Patients were evaluated every 12 hours, and visual analogue scale (VAS), verbal rating scale (VRS), extra opioid usage, nausea and vomiting (N& V), and sedation scores were recorded.Results: Patients’ nausea and vomiting and sedation scores were not statistically different between the three groups. Mean VAS and VRS scores were found to be statistically lower in the M20PC group than in the other groups. Extra opioid usage between the three groups was statistically lower in the M20PC group than in the other groups. The percentage of patients satisfaction was significantly higher in the M20PC group than in the other two groups.Conclusions: This study showed that, compared to simply increasing the dose of morphine, adding chlorpromazine, promethazine, midazolam, and clinidine to morphine significantly controlled pain scores and increased treatment satisfaction in addicted patients without notable side effects.

Background: Tricyclic antidepressants (TCAs) are commonly used orally for treating chronic pain states, such as neuropathic pain. TCAs produce analgesia by various mechanisms, including sodium channels, N-methyl-d-aspartate receptors, biogenic amines, opioids, inflammatory mediators, and substance P. Studies have shown that intrathecal tricyclic administration effectively attenuates pain and thermal hyperalgesia in inflammatory and neuropathic pain in rats.Objectives: The aim of this study was to evaluate the effect of two tertiary TCAs in sensory and motor block. We also used bupivacaine as a strong local anesthetic for the control group.Materials and Methods: In a double-blind randomized controlled trial in an animal lab, intrathecal injection of drugs was performed in 30 Wistar male rats. We divided the subjects into 3 groups: group 1: 90 mL Doxepine (50 mM), group 2: 90 ml amitriptyline (60 mM). and group 3: 90 mL bupivacaine (23 mM). Then sensory, motor, and proprioceptive changes were measured at 1, 2, 3, 4, 6, and 12 hours by one examiner.Results: In Groups 1 and 2, a total of 3 rats died. After adjusting the concentrations, amitriptyline had a similar potency but a longer duration of spinal blockade of motor, proprioception, and nociception than did bupivacaine (p<0.05), whereas doxepin had a reasonable but lower efficacy and shorter duration of spinal blockade than did bupivacaine (p<0.05). The full recovery time for Group 2 was significantly longer.Conclusions: It seems that tertiary amine drugs such as amitriptyline and doxepin had reasonable potencies of spinal blockade when compared to bupivacaine. However, amitriptyline had a more potent and long-acting spinal anesthetic effect. Amitriptyline may turn out to be a clinically valuable local anesthetic.

Background: Back pain is one of the most prevalent health problems for which physicians are consulted. Back pain has many economic impacts, such as sickness absences and long-term disability. The prevalence of major depression in patients with chronic low back pain is approximately 3 to 4 times greater than the prevalence rate reported in the general population.Objectives: This study was designed to evaluate the depression and disability improvement after lumbar discectomy compared with presurgery levels in patients with chronic low back pain and radicular leg pain.Patients and Methods: One hundred forty-eight patients with chronic low back pain and radicular leg pain were included in this analytic observational study. The study evaluated several main variables, including age, sex, educational level, job, height, weight; and patient history of abortion, leg pain, back pain, smoking, trauma, number of previous pregnancies, driving, long-term sitting, lifting heavy bodies, and disability and depression before and 6 and 12 months after laminectomy.Results: The depression and disability scores of patients before lumbar discectomy significantly decreased after surgery.Conclusions: Our results indicate that lumbar discectomy surgery significantly improved depression and disability in patients with chronic herniated discs.

Background: Opioid analgesics are commonly added to epidural local anesthetics to improve analgesia during surgery.Objectives: The goal of this study was to evaluate the maternal and neonatal effects of adding different doses of tramadol to 2% lidocaine in the epidural anesthesia for cesarean section.Patients and Methods: Ninety pregnant patients who were candidates for cesarean section under epidural anesthesia were randomly categorized into three groups. Group L received 2% lidocaine. In the LT50 and LT100 groups, 50 and 100 mg of tramadol were added to epidural 2% lidocaine. For additional analgesia during surgery, 2% lidocaine through epidural catheter or IV sufentanil were administered. Analgesia after surgery was provided by IV injection of meperidine. Onset and duration of sensory and motor blockades, total drug consumption, neonatal Apgar score, and complications were recorded.Results: In the LT100 group, onset of complete sensory and motor blockade at T6 was less than in the two other groups, but the highest level of sensory blockade and two segment regression and duration of motor blockades between the LT50 and LT100 groups were not significantly different, although they were higher and more prolonged than in the L group. Average lidocaine and sufentanil consumption during surgery between the LT50 and LT100 groups were not significantly different but were lower than in the L group. The incidence of maternal complications and neonatal Apgar scores were not significantly different between the three groups. In the LT50 and LT100 groups, the time until the first request for analgesics after surgery was prolonged, and average meperidine consumption was less than in the L group.Conclusions: The addition of tramadol to epidural 2% lidocaine offers advantages in cesarean section.

Background: Intentional lowering of blood pressure helps to produce a desirably clean surgical field. Many drugs can be used to induce a hypotensive state, but due to their high potency and rapid effect, drugs that more easily and safely control the induction of hypotension are desirable.Objectives: To investigate the effects of premedication with oral clonidine on intraoperative bleeding and hemodynamic variables in patients undergoing cesarean sections.Patients and Methods: A total of 110 patients classified as American Society of Anesthesiologists (ASA) physical status I and II and who were scheduled for elective cesarean section under general anesthesia were enrolled. The patients were randomized to receive either oral clonidine (0.2 mg) or identical-looking placebo tablets 90 minutes before arriving at the operating room. Induction of anesthesia was performed by the same standard protocol in all patients. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) and heart rate (HR) were recorded before and after induction; immediately after intubation; 5, 10, and 15 minutes thereafter; at the time of extubation; and one hour after the operation. The surgeons were asked to rate the quality of the operative field on a four-point scale that ranged from mild to abundant bleeding.Results: Intraoperative SBP was lower in the clonidine group. After both intubation and extubation, the increases in SBP, DBP, and HR in clonidine-treated subjects were significantly less than the changes in the control patients. The amount of fentanyl given to control blood pressure and HR was significantly less in the clonidine group (18 ± 38 vs.39 ± 53 mg, p=0.02). The responses to the four-point scale indicated that intraoperative bleeding in the clonidine group was less than in the placebo group (1.2 ± 0.4 vs.1.7 ± 0.6, p<0.05).Conclusions: Premedication with oral clonidine can improve the hemodynamic management of cesarean cases.

There are several etiologies for agitation and headache in the recovery room, including preoperative or intraoperative drug administrations, physical disorders such as painful surgical procedures, and finally, unusual consequences of some operations such as subarachnoid hemorrhage after orbital decompression, a disastrous complication that should be particularly considered whenever facing any sort of headache or unattainable full recovery. In this study a rare case of subarachnoid hemorrhage is presented.