Anesthesiology and Pain Medicine
Year:2015 | Volume:5 | Issue:3|Papers Count:10

Background: TRUS-guided needle biopsy of the prostate gland is the current standard method used for diagnosis of prostate cancer. Pain control during this procedure is through the use of i.v. sedation or local anaesthetic (LA), depending on clinician preference.Objectives: The aim of this study was to evaluate the effectiveness of intrarectal lidocaine, lidocaine-diltiazem and lidocaine-meperidine-diltiazem gel for anesthetizing transrectal ultrasound guided prostate biopsy.Patients and Methods: In a randomized double-blind clinical trial, 100 consecutive patients were divided into three groups. The patients received one of the gels before transrectal ultrasound guided prostate needle biopsy: group A, intrarectal and perianal lidocaine, gel 1 g; group B, intrarectal lidocaine gel, 1 g, + perianal diltiazem, 1 g; group C, intrarectal lidocaine gel, 1 g, + meperidine, 25 mg, and perianal diltiazem, 1 g. Visual analog pain scale was used to estimate pain during probe insertion and biopsy. Heart rate and blood pressure during probe insertion and biopsy were recorded too.Results: The mean of visual analog pain scale was 4.5 in group A, 3.5 in group B, and 2.0 in group C during probe insertion (P value=0.01). The mean of visual analog pain scale was 5.1 in group A, 3.5 group B, and 2.5 in group C during biopsy (P value=0.001). The groups were comparable for patients' age, weight, serum prostate-specific antigen (PSA), and prostate size (P>0.05). No side effects of meperidine and lidocaine including drowsiness, dizziness, tinnitus and light-headedness or requiring assistance for activity were noted.Conclusions: Lidocaine-meperidine-diltiazem gel provides significantly better pain control than lidocaine-diltiazem gel and lidocaine gel alone during transrectal ultrasound guided prostate biopsy and probe insertion. This mixture gel is safe, easy to administer and well accepted by patients.

Background: Endotracheal Tube Cuff Pressure (ETCP) should be kept in the range of 20-30 cm H2O. Earlier studies suggested that ETCP assessment by palpation of pilot balloon results in overinflation or underinflation and subsequent complications such as tracheal wall damage and aspiration.Objectives: The current study aimed to evaluate the effect of an in vitro educational program on the ability of anesthesia personnel to inflate Endotracheal Tube Cuffs (ETT) within safe pressure limits.Patients and Methods: The survey included two series of blinded ETCP measurements in intubated patients before and two weeks after an in vitro educational intervention. The in vitro educational program included two separate trials. The anesthesia personnel were asked to inflate an ETT cuff inserted in a tracheal model using their usual inflation technique. In the same session, six ETTs at different pressure levels were examined by the participants and their estimation of ETCP was recorded. After the in vitro assessment, the participants were informed about the actual pressure of the in vitro ETCPs and were allowed to train their fingers by in vitro pilot balloon palpation with validated manometer measurements.Results: The mean ETCP after the in vitro survey was significantly lower than the mean ETCP before the intervention (45±13 vs. 51±15 cm H2O, P=0.002). The rate of measurements within the safe pressure limits significantly improved after the in vitro education (24.2% vs. 39.7%, P=0.002).Conclusions: Implementing educational programs with the introduction of estimation techniques besides the use of manometer as a standard intraoperative monitoring will improve the safety of the practice.

Background: Postoperative sore throat is one of the most common complications after endotracheal intubation. Both Ketamine and magnesium can block N-methyl-D-aspartic acid (NMDA) receptors and provide central and local analgesia.Objectives: To compare the effect of magnesium sulfate and ketamine gargle on the incidence and severity of postoperative sore throat.Patients and Methods: A total of 100 patients candidate for emergency acute appendicitis surgery were enrolled in the study. Patients in ketamine group received ketamine gargle (0.5 mg/kg) and magnesium group received magnesium sulfate gargle (20 mg/kg up to 30 mL dextrose water 20%) 15 minutes before the operation. Patient complaint of postoperative sore throat, and its severity measured by visual analogue scale (VAS) were recorded at baseline in recovery room, and then 2, 4, and 24 hours after operation.Results: There were no significant differences between age, sex, and body mass index (BMI) between two groups of patients. Hemodynamics of patients, including blood pressure, respiratory rate, oxygen saturation %, and conscious state were not significantly different (P>0.05). Number of patients with sore throat were significantly lower in magnesium group compared to ketamine group at 2 (P=0.032), 4 (P=0.02), and 24 hours (P=0.01) after the operation. Sore throat pain score (VAS) was significantly lower in magnesium group compared to ketamine group at 2 (P=0.019), 4 (P=0.028), and 24 hours (P=0.014) after the operation.Conclusions: Magnesium at low dose decreases sore throat and pain severity more effectively compared to ketamine gargle.

Background: The use of Propofol often results in pain upon injection, which is sometimes very distressing for patients. Many patients report some degree of pain or discomfort on injection with propofol. Injection-induced pain during induction of anesthesia can result in patient's discomfort.Objectives: This study was performed to evaluate the effects of nitroglycerine on pain severity in patients undergoing propofol injection.Patients and Methods: In this double-blind randomized clinical trial, 100 patients with ASA class I and II undergoing anesthesia with propofol injection were selected for the study from 2012 to 2013 in Imam Reza training hospital. Patients were randomly assigned to case and control groups and received either 20 mg of nitroglycerine or normal saline as placebo. The severity of injection pain was assessed using a four-point scale. An anesthesiologist observed hemodynamic and local adverse effects.Results: The pain severity in nitroglycerine group was significantly lower compared with the placebo group (P<0.0001). Moreover, the local adverse reactions were observed only in three patients in the placebo group while no patient in the drug group experienced adverse effects (P=0.242). The systolic blood pressure showed no significant difference between two groups before and after the induction of anesthesia but the diastolic blood pressure and the heart rate was significantly different between study groups.Conclusions: Nitroglycerine may be a safe and effective adjuvant therapeutic for pain reduction in patients under propofol injection. Hence, its use for reduction of propofol injection-induced pain is recommended.

Background: Premedication is required for reducing anxiety and child’s struggling against mask acceptance on anesthesia in pediatric surgery for congenital heart disease. Midazolam has been widely used for this purpose, but because of its side effects, finding an effective replacement with less complication is necessary.Objectives: In the present study, we compared the efficacy of oral midazolam versus dexmedetomidine in terms of anxiolysis and mask acceptance behavior.Patients and Methods: Sixty children aged between 2 and 12 years, and scheduled for on-pump surgery due to a congenital heart disease were randomly assigned into two groups. Oral midazolam (0.5 mg/kg up to 15 mg per patient) and dexmedetomidine (2 mg/kg) were administered 45 minutes pre-anesthesia. Children’s anxiety, mask acceptance behavior, hemodynamic measures, and cardiopulmonary outcomes were recorded and compared.Results: The mean age of patients was 3.96 ± 2.04 years. Twenty-eight (46.7%) patients were females. Two drugs have similar effects on cardiopulmonary outcomes and hemodynamic measures (P>0.05). They equally relieved the children’s anxiety (mean sedation score 1.93±0.63 and 2.0±0.63 for midazolam and dexmedetomidine groups, respectively; P>0.05), while dexmedetomidine showed a better effect on improving the mask acceptance behavior (mean mask acceptance score 2.58±0.6 and 1.6±0.67 for midazolam and dexmedetomidine, respectively; P<0.05).Conclusions: It appears reasonable to apply oral premedication with dexmedetomidine 45 minutes before transferring the patient to the operating room when he or she is more prone to resist inhalation anesthesia induction.

Background: Diabetes mellitus (DM) is risk factor for complications after orthopedic surgery.Objectives: We tested the hypothesis that anesthesia preoperative clinic (APC) referral for elevated glycosylated hemoglobin (HbA1c) reduces complication rate after total joint arthroplasty (TJA).Patients and Methods: Patients (n=203) with and without DM were chosen from 1,237 patients undergoing TJA during 2006-12. Patients evaluated in the APC had surgery in 2006-8 regardless of HbA1c (uncontrolled). Those evaluated between in subsequent two-year intervals were referred to primary care for HbA1c ≥10% and ≥8%, respectively, to improve DM control before surgery. Complications and mortality were quantified postoperatively and at three, six, and twelve months. Length of stay (LOS) and patients requiring a prolonged LOS (> 5 days) were recorded.Results: Patients (197 men, 6 women) underwent 71, 131, and 1 total hip, knee, and shoulder replacements, respectively. Patients undergoing TJA with uncontrolled HbA1c and those with HbA1c <10%, but not those with HbA1c <8%, had a higher incidence of coronary disease and hypercholesterolemia than patients without DM. An increase in complication rate was observed in DM patients with uncontrolled HbA1c versus patients without DM (P<0.001); the complication rate progressively decreased with tighter HbA1c control. More DM patients with preoperative HbA1c that was uncontrolled or ≥10% required prolonged LOS versus those without DM (P<0.001 and P=0.0404, respectively).Conclusions: APC referral for elevated HbA1c reduces complication rate and the incidence of prolonged hospitalization during the first year after surgery in diabetics undergoing TJA.

Background: Irreversible electroporation (IRE) is a relatively new approach to the management of multiple types of locally advanced soft tissue tumors. Unique peri-procedural anesthetic management is needed in the safe and effective delivery of this therapy.Objectives: This study analyzed IRE therapy in relation to anesthetic management for our initial cohort and then established and validated a set of best practical guidelines for general anesthesia in patients undergoing IRE for abdominal tumors.Patients and Methods: An IRB-approved prospective data collection outcome protocol was utilized. This study was broken up into two cohorts as follows: the initial 38 patients (pts) undergoing IRE in which anesthetic management was not defined or optimized and then a 40-pt validation cohort to establish the most efficacious anesthetic protocols.Results: During IRE delivery, a deeper neuromuscular blockade is required to ensure that all retroperitoneal muscle excitation was minimized. In the initial 38-pt cohort, attempts to treat hypertension (median SBP 190, range 185-215 and median diastolic 98, range 91-115) were made with various types of anti-hypertensives with minimal-to-insufficient effects. The established inhalation was sevoflurane with an approximate median dose of 8.0 volume percentage. Analgesic management of continuous remifentanil was utilized with epidural management, which optimized HTN and tolerance to IRE therapy.Conclusions: Anesthetic management for IRE of soft tissue deviates from standard anesthetic medical therapy in regards to depth of neuromuscular blockade and analgesic management during IRE energy delivery. However, minor modifications in anesthesia management allow for a safe and efficient patient procedure.

Background: Arthroscopic knee surgery is commonly performed as an outpatient procedure and is often associated with postoperative pain.Objectives: We aimed to compare the effects of intra-articular levobupivacaine-tenoxicam-tramadol and levobupivacaine-tenoxicam-morphine combinations on postoperative pain in patients undergoing elective arthroscopic knee surgery.Materials and Methods: A total of 90 ASA I-II patients undergoing elective arthroscopic meniscectomy under general anesthesia were enrolled. The participants were randomly allocated to three groups to receive the following intra-articular medications after completion of the surgery and before deflation of the tourniquet: Group S, 20 mL of saline; Group T, 35 mg of levobupivacaine, 20 mg of tenoxicam, and 100 mg of tramadol in 20 mL saline; and Group M, 35 mg of levobupivacaine, 20 mg of tenoxicam, and 4 mg of morphine in 20 mL saline. Visual analogue scale values at rest (VASr) and at active flexion of knee (VASa) at postoperation hours 1, 2, 4, 8, 12, and 24, duration of analgesia, total analgesic consumption, and number of rescue analgesia at 24 hours were evaluated.Results: VASr and VASa were significantly higher in group S in comparison to other groups (P<0.05). Duration of analgesia was significantly longer in Group T and Group M than in Group S (P<0.05). The difference between group T and group M was also significant (P<0.05). Number of rescue analgesia and total analgesic consumption at postoperative hour 24 was significantly fewer in group M compared with other groups (P<0.05).Conclusions: Intra-articular levobupivacaine-tenoxicam-morphine combination provides effective pain relief, longer analgesic duration, and less analgesic requirement when compared with intra-articular levobupivacaine-tenoxicam-tramadol combination and saline after knee arthroscopic surgery.

Background: Spinal anesthesia is widely used for caesarean section. Addition of intrathecal magnesium sulfate to local anesthetics seems to improve the quality of block and prolong the duration of analgesia.Objectives: The present study was designed to examine whether addition of intrathecal magnesium sulfate enhances the analgesic efficacy of intrathecal bupivacaine in patients undergoing cesarean section.Patients and Methods: We conducted a randomized, prospective, double-blind, case-control, clinical trial. Eighty patients were scheduled for cesarean section under spinal anesthesia. The patients were randomly allocated to receive either 10 mg of hyperbaric bupivacaine 0.5% (control group) or 10 mg of hyperbaric bupivacaine 0.5% plus 50 mg magnesium sulfate (case group) intrathecally. Hemodynamic variability, onset and duration of block and duration of analgesia were evaluated.Results: The onset of sensory blockade was delayed in case group compared with control group, and this was statistically significant. The onset of motor blockade had no difference in both groups. The duration of motor blockade was similar. Post-operative analgesia was longer in magnesium sulfate group but the difference was not meaningful. The intraoperative hemodynamic variability showed no significant differences between groups.Conclusions: This study showed that the addition of intrathecal magnesium sulfate to bupivacaine is not desirable in patients undergoing cesarean section due to the delay in the onset of sensory blockade and the lack of significant effects of magnesium on post-operative pain.

Background: Nerve damage after regional anesthesia has been of great concern to anesthetists. Various modalities have been suggested to recognize and prevent its incidence. An understudied area is the measurement of intraneural pressure during peripheral nerve blockade. Previous investigations have produced contradicting results with only one study being conducted on human cadavers.Objectives: The purpose of this investigation was to systematically record intraneural and perineural injection pressures on the median, ulnar, and radial nerves exclusively as a primary outcome.Materials and Methods: Ultrasonography-guided injections of 1 mL of 0.9% NaCl over ten seconds were performed on phenol glycerine embalmed cadaveric median, ulnar, and radial nerves. A total of 60 injections were performed, 30 intraneural and 30 perineural injections. The injections pressure was measured using a controlled disc stimulation device. Anatomic dissection was used to confirm needle placement.Results: Intraneural needle placement produced significantly greater pressures than perineural injections did. The mean generated pressures in median, radial, and ulnar nerves were respectively 29.4±9.3, 27.3±8.5, and 17.9±7.0 pound per square inch (psi) (1 psi=51.7 mmHg) for the intraneural injections and respectively 7.2±2.5, 8.3±2.5, and 6.7±1.8 psi for perineural injections. Additionally the intraneural injection pressures of the ulnar nerve were lower than those of the median and radial nerves.Conclusions: Obtained results demonstrate significant differences between intraneural and perineural injection pressures in the median, ulnar, and radial nerves. Intraneural injection pressures show low specificity but high sensitivity suggesting that pressure monitoring might be a valuable tool in improving the safety and efficacy of peripheral nerve blockade in regional anesthesia. Peripheral nerves “pressure mapping” hypothetically might show difference amongst various nerves depending on anatomic location, histologic structure, and ultrasonographic appearance.