Anesthesiology and Pain Medicine
Year:2014 | Volume:4 | Issue:4|Papers Count:16

Dear EditorWe read A Rare Central Venous Catheter Malposition: A Case Report by Moeinipour et al. with interest. Insertion of central venous catheters (CVCs) is without a doubt an essential component of both peri-operative and critical care monitoring and management. It is also considered as a fundamental skill to achieve Certificate of Completion of Training for any anaesthetic trainees in the United Kingdom. Insertion of CVCs is associated with complications in more than 15% of patients, mainly mechanically, from infection and from thromboembolic events.

Background: Cognitive disorder, which is a common problem for the hospitalized patients, is a fluctuating cognitive destruction that leads to the loss of consciousness. It is usually accompanied by increased mortality, prolonged hospital stay, and decreased rehabilitation.Objectives: The purpose of this study was to determine the risk factors associated with cognitive disorder after coronary artery bypasses graft surgery (CABG).Patients and Methods: A total of 171 patients who had undergone off-pump CABG without any history of psychiatric disorders were enrolled. Samples were selected according to a purposive sampling method. The Mini-Mental State Examination (MMSE) questionnaire was given to each patients to assess the incidence of cognitive disorder during the first 24 hours of surgery in ICU. To compare creatinine, erythrocytes sedimentation rate, extubation time, and patients’ age between those with and those without postoperative cognitive disorder, independent-samplest test was employed. To compare two groups in terms of any history of diseases such as diabetes, hypertension, and hyperlipidemia, and qualitative C-reactive protein (CRP), Chi square test was used.Results: Results showed that 75% of patients had postoperative cognitive disorder. There was a significant association between the history of hypertension, CRP, and preoperative creatinine levels in both cognitive disorder and control groups.Conclusions: Given the significant prevalence of postoperative cognitive disorder and significant association between the history of hypertension, CRP, and preoperative creatinine and cognitive disorder, the detection of patient’s clinical symptoms may improve diagnosis, treatment, and even prevention of cognitive disorder.

Background: Active muscular trigger points (aMTPs) presenting with radiating pain can interfere in diagnosis and treatment of patients suffering from lumbosacral radiculopathy.Objectives: We aimed to diagnose and evaluate the trigger point therapy on the outcome of pain in patients with lumbosacral radiculopathy.Materials and Methods: A total of 98 patients were enrolled suffered with chronic pain andlumbosacral radiculopathy at L4-L5 and L5-S1 who were candidates of non-surgical management. All patients received conservative modalities, including bed rest, non-steroidal anti-inflammatory agents (NSAID), and physiotherapy. These treatments continued for a week. Patients were examined for the presence of trigger points in their lower extremities. Those who had trigger points were divided into 2 groups (TP and N). Patients in TP group underwent trigger point injection therapy. No further therapy was done for the N group. Pain scores and straight leg raise (SLR) test in both groups were collected and analyzed on the seventh and 10th days of the therapy. Results were analyzed by paired t test and chi-square test.Results: Out of 98 patients, 64 had trigger points. Thirty-two patients were assigned to each group. Pain scores (Mean±SD) in TP group was 7.12±1.13 and in N group was 6.7±1.16, P=0.196. Following the treatment, pain scores were 2.4±1.5 in TP group and 4.06±1.76 in N group P=0.008. SLR test became negative in all patients in TP group but only in 6 (19%) patients in N group, P=0.001.Conclusions: Results show that trigger point injection therapy in patients suffering from chronic lumbosacral radiculopathy with trigger points can significantly improve their recovery, and conservative therapy may not be adequate.

Background: Sufentanil and alfentanil have pharmacokinetic and dynamic properties which make them favourable substances for total intravenous anesthesia (TIVA) in combination with propofol.Objectives: We planned to compare two clinical protocols for TIVA with propofol, and either sufentanil or alfentanil in regards to postoperative pain, hemodynamic stability during the case and time for emergence from anesthesia.Patinets and Methods: Treaty eight patients scheduled for general anesthesia for breast surgery were included in this Double-blind, randomized, controlled trial. All patients received a standardized TIVA with propofol and either 0.2 mg kg-1 sufentanil or 20 mg kg-1 alfentanil for induction and 0.3 mg kg-1 h-1 sufentanil or 30 mg kg-1 h-1 alfentanil for maintenance with additional propofol boluses as needed. During anesthesia, heart rate, non-invasive blood-pressure, peripheral oxygen saturation and depth of anesthesia, were recorded. In the post anesthesia care unit, pain scores, nausea and vomiting as well as medications were recorded.Results: Patients in the sufentanil group required less often additional opioid and propofol boluses to maintain adequate anesthesia. We did not observe a significant difference in time to extubation. Postoperatively, patients in the sufentanil group had less pain (P=0.03) and required less i.v. opioids (0.4 vs.1.9 mg piritramid, P=0.04).Conclusions: Both protocols provide excellent anesthesia, but patients receiving sufentnail had more stable anesthesia and less postoperative pain.

Context: Alterations in taste and smell, including but not limited to anosmia, ageusia, hypogeusia, and dysgeusia, have been described in association with various medications, including anesthetic agents. Frequently, these symptoms occur 1-2 weeks after medication administration and last several months. While such a phenomenon is a rare occurrence, it nonetheless can significantly impact patients’ satisfaction and quality of life.Evidence Acquisition: The methodology consisted of a thorough literature search using the MEDLINE and Cochrane databases utilizing keywords such as anosmia, ageusia, olfactory disorders, postoperative, and anesthesia.Results: Our results yielded several previously published case report, and were not limited to a specific type of anesthesia. Based on available literature, we review the physiology of taste and smell as well as the medications associated with loss of these senses. We describe perioperative agents that could lead to postoperative complications associated with anosmia and and ageusia.Conclusions: Based on available literature recommendations for anesthesiologists caring for patients at risk for this occurrence are presented in this review. The symptoms are usually temporary as in the majority of the patients the sensory receptor cells are able to regenerate themselves after injury. Anesthesia providers need to aware of this phenomenon to be able to reassure patients and possibly avoid anesthetic techniques associated with anosmia and ageusia.

Background: Postoperative pain is a major complaint following laparoscopic cholecystectomy.Objectives: The aim of this study was to compare the impact of intraperitoneal hydrocortisone with intraperitoneal bupivacaine on pain relief after laparoscopic cholecystectomy.Patients and Methods: In a double blind clinical trial, 63 candidates for laparoscopic cholecystectomy were randomly allocated to receive intraperitoneal instillation of either 100 mg bupivacaine in 250 mL normal saline (n=32) or 100 mg hydrocortisone in 250 mL normal saline (n=31) before insufflation of CO2 into the peritoneum for postoperative pain relief. Patients were investigated regarding abdominal and shoulder pain using (visual analog scale) VAS in recovery room and at 6, 12 and 24 hours postoperatively. Patients were also followed regarding postoperative analgesic requirements, nausea and vomiting, and return of bowel function.Results: Sixty patients completed the study. Patients in the hydrocortisone group had no statistically significant abdominal and shoulder pain scores compared to the bupivacaine group. The patients were similar regarding postoperative analgesic requirements, return of bowel function, nausea and vomiting. No adverse effect was detected in either group.Conclusions: Intraperitoneal administration of hydrocortisone is as effective as bupivacaine to reduce pain and analgesic requirements after laparoscopic cholecystectomy.

Background: Cognitive disorder is a fluctuating cognitive destruction and a common problem for hospitalized patients, which leads to loss of consciousness. It is usually accompanied with increased mortality, prolonged hospital stay, and decreased rehabilitation.Objectives: The purpose of this study was to determine risk factors associated with cognitive disorder after open-heart surgery.Patients and Methods: In total, 171 patients who had undergone off-pump open-heart surgery and lacked any history of psychiatric disorders were enrolled. Samples were selected according to a purposive sampling method. The Mini-Mental State Examination questionnaire was used for these patients to assess the incidence of cognitive disorder 24 hours after the operation in ICU and to compare creatinine level, ESR, extubation time and patients’ age in the two groups, one with postoperative cognitive disorder and the other without it. Independent T-test was used to compare the two groups regarding any history of diseases such as diabetes, hypertension and hyperlipidemia, Chi square test was used.Results: In total, 75% of patients had postoperative cognitive disorder. There was a significant association between the history of high blood pressure, C-reactive protein and preoperative creatinine levels in both cognitive disorder and control groups.Conclusions: Given the significant prevalence of postoperative cognitive disorder and significant associatio n between the history of high blood pressure, C-reactive protein and preoperative creatinine and cognitive disorder, detection of patient’s clinical symptoms may improve diagnosis, treatment and prevention of this disorder.

Background: Spinal anesthesia has been associated with intraoperative nausea and vomiting (IONV), especially during cesarean section, which is attributed to several mechanisms.Objectives: In the present study, therapeutic and preventive properties of sub hypnotic dose midazolam and propofol and their effects on the occurrence and severity of intraoperative nausea and vomiting during elective cesarean section under spinal anesthesia were evaluated.Patients and Methods: In a randomized, double-blind, and placebo-controlled clinical trial, 90 parturients, ASA class I and II, aged 20-30 years, who undergone spinal anesthesia for cesarean section were randomly allocated to one of three groups receiving midazolam (1 mg bolus and 0.1 mg/kg/hr, n=30), propofol (20 mg bolus and 0.1 mg/kg/hr, n=30), and placebo (saline, n=30) intravenously (IV) immediately after umbilical cord clamping. Bupivacaine hydrochloride (10 mg) was used for induction of the anesthesia. Patients’ hemodynamics was monitored at 3-minute intervals. Furthermore, intraoperative and post-delivery emetic episodes, severity of emesis, scores of sedation and ephedrine consumption were recorded.Results: The incidence of nausea, retching, and vomiting was significantly higher in the control group compared to propofol and midazolam groups. Overall, PONV (postoperative nausea and vomiting) in midazolam group was as low as propofol group without any significant hemodynamic changes as seen in placebo group or even with propofol group.Conclusions: Subhypnotic doses of midazolam or propofol are effective in the prevention of nausea and vomiting during and after cesarean section with spinal anesthesia and does not significantly influence hemodynamic of the patients.

Background: Antioxidant effects of propofol (2, 6-diisopropylphenol) were evaluated against cisplatin-induced oxidative stress in rat.Objectives: In this experimental study, 20 male rats were equally divided into 4 groups (5 rats each), and were treated by propofol (10 mg/kg/day, IP), or cisplatin (7 mg /kg/day, IP), or both.Materials and Methods: Group one was control, while group 2 was given cisplatin (7 mg /kg/day, IP). Animals of the third group received only propofol (10 mg/kg/day, IP). Group 4 was given propofol with cisplatin once per day for 7 days. After treatment, blood urea nitrogen, creatinine levels, and oxidative stress m arkers such as total thiol groups (TTG), lipid peroxidation (LPO), and total antioxidant capacity (TAC) were measured.Results: Oxidative stress induced by cisplatin, was evident by a significant increase in LPO and decrease in TTG and TAC. Propofol recovered cisplatin-induced changes in TAC, TTG and LPO in blood.Conclusions: It is concluded that oxidative damage is the mechanism of cisplatin toxicity, which can be recovered by propofol.

Introduction: Lung isolation is a common technique used in thoracic surgery to prevent spillage to unaffected lung and to provide a better view for the surgeon.Case Presentation: A 41-year-old woman with a history of pharyngo-laryngo-oesophagectomy (PLO) and tracheostomy was a candidate for thoracic duct ligation because of chylothorax. Since the patient had tracheostmy stomal stenosis, two cuffed tracheal tubes (internal diameter=4.5 mm) were used; one tube was placed in the right bronchus and the other tube in the left one by fiberoptic laryngoscopy in 10 minutes. Right lung was collapsed during the surgery for 3.5 hours with a slight decrease in oxygenation (SpO2=91%–93%) and with no evident hemodynamic change. Potential trauma from a double-lumen tube and a bronchial blocker as well as inaccessibility to a univent tube prevented us to use these standard methods in this case.Conclusions: This report presents a new method for lung isolation in specific cases and in the absence of certain equipment.

Background: A defasciculating dose of non-depolarizing muscle relaxant administered prior succinylcholine decrease its side effects including fasciculations and postoperative myalgias; however it is believed that the dosage of succinylcholine should be increased when such a pre-treatment is used.Objectives: We hypothesized that a defasciculating dose of pancuronium as a pre-treatment could prolong its duration of effect.Patients and Methods: Forty patients scheduled for elective orthopaedic surgery were consecutively assigned into 5 groups, a first group without pre-treatment (succinylcholine 1 mg/kg) and 4 subsequent groups of pretreatment with atracurium 0.05 mg/kg+succinylcholine 1 or 1.5 mg/kg and pancuronium 7.5 mg/kg+succinylcholine 1 and 1.5 mg/kg. The muscle relaxant effect of succinylcholine was assessed with a force transducer using train of four stimulations every 12 seconds. Kruskall Wallis Anova test was used to compare results.Results: The duration of succinylcholine induced paralysis (1 and 1.5 mg/kg) was significantly prolonged with pre-treatment with pancuronium but succinylcholine 1mg/kg did not reached maximum blockade after pre-treatment with atracurium. After pancuronium, full recovery after succinylcholine 1.5 and 1 mg/kg occurred respectively after 18 and 15 minutes. P<0.05 vs.12 minutes for succinylcholine 1mg/kg alone.Conclusions: This study highlights potentiation effect of a defasciculating dose of pancuronium on succinylcholine paralysis suggesting the lack of justification to increase succinylcholine dosage.

Introduction: The authors performed videolaryngoscopy during the preoperative anesthesia clinic evaluation of a patient with chronic dyspnea, stridor, and a previous hemilaryngectomy scheduled to undergo a series of orthopedic surgery procedures for an infected knee arthroplasty. The findings proved crucial for determining airway management.Case Presentation: A 68-year-old man presented to the preoperative anesthesia clinic for work-up before anticipated removal of infected total knee arthroplasty hardware, placement of antibiotic spacers, incision and drainage procedures, and revision arthroplasty. The patient had previously undergone a hemilaryngectomy and tracheostomy (now closed) for squamous cell carcinoma of the right true vocal cord. The patient described chronic dyspnea with minimal exertion. Inspiratory and expiratory wheezes and intermittent inspiratory stridor were present. A transnasal videolaryngoscopy examination was performed using topical anesthesia and demonstrated significant supraglottic scarring, a narrowed glottis, and subglottic stenosis. A computed tomography study confirmed the presence of tracheomalacia with subglottic stenosis. A permanent tracheostomy was performed to establish a definitive airway before the knee arthroplasty was removed.Conclusions: The case illustrates that transnasal videolaryngoscopy conducted in the preoperative anesthesia clinic is capable of providing key information to guide airway management in patients with significant upper airway pathology.

Background: Spinal anesthesia (SA) is the most common regional anesthesia (RA) conducted for many surgical procedures.Objectives: The current study aimed to predict the difficulty score of SA, by which to reduce the complications and ultimately improve the anesthesia quality.Materials and Methods: Transurethral Lithotripsy (TUL) surgery candidates were enrolled in this observational study from 2010 to 2011. Before SA, the patient`s demographic information along with the Body Mass Index (BMI), lumbar spinous process status, spinal deformity, radiological signs of lumbar vertebrae, and a history of spinal surgery or difficult SA were recorded, then the patients underwent SA in L3-L4 interspinous process space. Information about Cerebrospinal Fluid (CSF) visibility at the first attempt (easy SA) and the times of trying with shifting in that space or trying the second space (moderate SA) and the third space (difficult SA) were recorded. Multinominal regression and relative operating characteristic (ROC) curve were used for statistical analysis.Results: Hundred and one patients were enrolled. Of these patients, 50 (49.5%) underwent SA by the first attempt of the first space, in 36 patients (35.6%) it was moderate and in 15 patients (14.9%) it was difficult. There was no significant relationship between difficulty score of SA and gender, age, height, and history of previous difficult SA. But there was a significant relationship between difficulty score of SA and lumbar spinous process status (P=0.0001), radiological profile of the lumbar spine (P=0.0001), the status of lumbar deformity (P=0.007), and BMI (P=0.006). Then using the ROC curve to predict the difficult SA, the cutoff point was 8.5 with 86.7% and 86% sensitivity and specificity, respectively.Conclusions: It seems that considering the clinical examination of patients before SA focusing on lumbar spinous process status, presence of lumbar deformity, calculation of BMI and radiological signs of lumbar vertebrae can be helpful in predicting SA difficulty.

Background: Gasretention in the peritoneal cavity plays an important role in inducing postoperative pain after laparoscopy, which is inevitably retained in the peritoneal cavity.Objectives: The aim of this study was to detect the relation between the volume of residual gas and severity of shoulder and abdominal pain.Patients and Methods: In this Prospective study 55 women who were referred for laparoscopic cholecystectomy, were evaluated for the effect of residual pneumoperitoneum on postlaparoscopic cholecystectomy pain intensity. The pneumoperitoneum was graded as absent, mild (1-5 mm), moderate (6-10 mm) and severe (>11 mm). Patients were followed for postoperative abdominal and shoulder pain using visual analogue scale (VAS), postoperative analgesic requirements, presence of nausea and vomiting, time of unassisted ambulation, time of oral intake and time of return of bowel function in the recovery room and at 6, 12 and 24 hours after operation.Results: At the end of the study, 17 patients (30.9%) had no residual pneumoperitoneum after 24 hours; which 23 (41.81%) had mild residual pneumoperitoneum, eight (14.54%) had moderate pneumoperitoneum and seven (12.72%) had severe pneumoperitoneum. Patients with no or mild residual pneumoperitoneum had significantly lower abdominal and shoulder pain scores than whom with moderate to severe pneumoperitoneum (P=0.00) and need less meperidine requirements (P=0.00). Patients did not have any significant difference in time of oral intake, return of bowel function, nausea and vomiting percentages.Conclusions: We conclude that volume of residual pneumoperitoneum is a contributing factor in the etiology of postoperative pain after laparoscopic cholecystectomy.

Background: Diabetic ketoacidosis (DKA) is an acute and life-threatening complication in diabetic patients. The current diagnostic criteria of DKA are metabolic acidosis, blood glucose level greater than 250 mg/dL and the presence of ketones in serum or urine. DKA patients referring to the emergency department (ED) are usually ill.Objectives: The present study aims to evaluate the efficacy of Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring in predicting the critically illness in the hyperglycemic patients referring to the ED.Patients and Methods: We performed a prospective cohort study in an ED. One hundred eighty one patients older than 18 years with hyperglycemia were included in our study. Following the primary evaluation, the subjects were divided into DKA and non-DKA patients. APACHE II scores were calculated for all patients and then compared to each other. We determined predictive value, sensitivity, specificity and cut-off points of APACHE II score for DKA.Results: Sixty two patients had DKA. The comparison of APACHE II score among two groups of the patients did not show any significant difference (P=0.597). There was no suitable cut-off point for APACHE II score to predict DKA.Conclusions: APACHE II score cannot be applied in the predicting of DKA in hyperglycemic patients admitted in ED.

Background: Simple and efficient way of pain management after Coronary Artery Bypass Graft (CABG) surgery is an important aspect of patients’ care.Objectives: This study aimed to compare the effects of morphine and diclofenac suppositories on postoperative pain management.Patients and Methods: In this double-blinded clinical trial study, 120 patients aged 30-65 years old, undergone CABG, were equally divided into two groups of A (morphine) and B (diclofenac). All patients were anesthetized with intravenous fentanyl 10 mg/kg, etomidate 0.2 mg/kg and cisatracurium 0.2 mg/kg. Anesthesia was maintained with oxygen 50% and air 50%, propofol 50 mg/kg/min, fentanyl 1-2 mg/kg/h and atracurium 0.6 mg/kg/h. Analgesics were administered after the operation at intensive care unit (ICU) and Visual Analogue Score (VAS) was evaluated in both groups in 4-hour intervals after extubation for 24 hours. After extubation in case of VAS>3, morphine suppository 10 mg (group A) or diclofenac suppository 50 mg (group B) was administered for patients.Results: No significant statistical relationship was found between the two groups regarding gender, age, BMI, paracetamol consumption, length of operation time, cardiopulmonary bypass pump (CPB) time, and stay time at ICU (P Value³0.05). Total dosage of used morphine was 22±8.3 mg in each patient and total dosage of used diclofenac was 94±32.01 mg. Average variation of VAS at measured intervals was significant (P Value£0.0001), but these variations were not significantly different when comparing the two groups (P Value=0.023).Conclusions: Both morphine and diclofenac suppositories reduced pain significantly and similarly after CABG surgery.