Anesthesiology and Pain Medicine
Year:2014 | Volume:4 | Issue:5|Papers Count:12

Introduction: We describe a patient scheduled for elective surgery who regularly consumed approximately 12 to 15 times the maximum recommended daily dose of dextromethorphan. We describe the clinical pharmacology of dextromethorphan and discuss its anesthetic implications.Case Presentation: A 30-year-old man with a history of a nasal fracture was scheduled to undergo an elective septorhinoplasty. He reported daily consumption of large quantities (1440 to 1800 mg) of dextromethorphan for six years. He was previously treated for dextromethorphan dependency on several occasions with urine dextromethorphan levels exceeding 2000 ng/mL. He described marked dissociative effects when abusing the drug, but had abstained from use for 48 hours before his elective surgery. Considering that dextromethorphan has a relatively short half-life and that the patient did not suffer major withdrawal symptoms after voluntarily discontinuing the drug, the authors proceeded with the case while recognizing that the drug has significant neuropsychiatric and sympathetic nervous system stimulant effects resulting from its actions as a N-methyl-D-aspartate receptor antagonist.Conclusions: Anesthesiologists need to be aware of dextromethorphan’s clinical pharmacology because recreational abuse of the drug has become increasingly common in adolescents and young adults.

Introduction: Most pain physicians know that fluoroscopy might improve the safety, accuracy, and efficacy of nerve block; however, it is difficult to distinguish the previously administered contrast medium from the injecting contrast medium, and to identify accurate contrast medium diffusion flow in a case of existing radiodensities such as cement and screw. Digital subtraction angiography (DSA) can improve accuracy of nerve blocks.Case Presentation: We described our experiences with two successful transforaminal epidural injections and nerve block of two patients with 73 and 68 years of age who were diagnosed as failed back surgery syndrome.Conclusions: The advantages of DSA in fluoroscopy-guided transforaminal epidural block and nerve block are identification of the degree of appropriate contrast flow (epidural and nerve root sleeve) and the intravascular administration without overlapping radiodense structures.

Background: Critically ill patients under mechanical ventilation require frequent suctioning of airway secretion. Closed suction permits suctioning without disconnection from ventilator; so it might decrease hypoxemia and infection rate.Objectives: This study aimed to evaluate t he effect of closed tracheal suction system (CTSS) versus open tracheal suction system (OTSS).Patients and Methods: This is a prospective randomized study, which was carried on 100 patients in surgical Intensive Care Unit requiring mechanical ventilation for more than 48 hours from June 2012 to November 2013. In two groups, suction was performed based on the patients' need as well as physician's or nurses' decision on tracheal secretions. Patients randomly allocated into two groups (50 patients each): CTSS group and OTSS group. Patients were monitored for developing ventilator-associated pneumonia (VAP) during the study. Throat samples were taken on admission and two times per week from each patient. Tracheal samples were performed during endotracheal intubation, two times per week during mechanical ventilation and during extubation.Results: Drainage of subglottic secretions decreased the incidence of VAP (P<0.05). Also type of the pharmacologic medicine for stress ulcer prophylaxis has significant effect on VAP incidence. Among the patients in OTSS and CTSS groups, 20% and 12% developed VAP, respectively. Use of CTSS compared with OTSS did not show statistically significant effect on VAP incidence in multivariate analysis; however, OR (odds ratio) tended to identify OTSS as an exposure factor for the development of VAP (OR=1.92; CI=0.45-8.30; =0.38) compared with the CTSS. Higher levels of APACHE II score, sinusitis and tracheostomy put the patients at the risk of VAP. However, using heat and moisture exchanger (HME) instead of humidifier decreased this risk.Conclusions: Based on the results obtained from our study, impact of suctioning is similar between CTSS and OTSS regarding the occurrence of VAP. It seems that physicians must consider many factors such as duration of mechanical ventilation, comorbidities, oxygenation parameters, number of required suctioning, and the cost prior to using each type of tracheal suction system.

Background: Nowadays laryngeal mask airway (LMA) is popular as one of the best choices for airway management. Low-flow anesthesia has some advantages like lower pollution, hemodynamic stability and cost effectiveness. Volatile anesthetics are widely used for anesthesia maintenance during operations. Sevoflurane has more hemodynamic stability compared to isoflurane, but there are few studies comparing the hemodynamic stabilities of these two anesthetics during controlled low flow anesthesia with LMA.Objectives: The aim of this study was to compare the effects of low-flow sevoflurane and low-flow isoflurane on hemodynamic parameters of patients through LMA.Patients and Methods: Eighty patients, scheduled for elective ophthalmic surgery, were randomly divided into two groups. After induction, an LMA with an appropriate size was inserted in all the patients and they were randomly allocated to two groups of low-flow sevoflurane (n=40) and low-flow isoflurane (n=40). Hemodynamic parameters (heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and Mean Arterial Pressure (MAP) were recorded at 5, 10, 15, 20, 25 and 30 minutes after the anesthesia induction.Results: The mean heart rate values were significantly less in the sevoflurane group (P value < 0.05) at 25 minutes after the surgery. The mean Blood Pressure in the isoflurane group was significantly higher compared with the sevoflurane group in 10, 20 and 30 minutes after the surgery (P values=0.0131, 0.0373 and 0.0028, respectively). These differences were clinically unimportant because heart rate and mean blood pressure were on normal ranges.Conclusions: Seemingly, low-flow sevoflurane with LMA did not have any significant hemodynamic effect on clinical practice. Therefore, low-flow sevoflurane anesthesia with LMA might be considered in patients with short operations who need rapid recovery from anesthesia.

Background: Pain management after cardiac surgery has been based on parenteral long-acting opioids such as morphine. The other alternatives are paracetamol and remifentanil.Objectives: In this prospective, double-blind, randomized study, we compared the efficacy of intravenous patient-controlled analgesia (IV-PCA) paracetamol and remifentanil for post cardiac surgery pain relief.Materials and Methods: One-hundred patients scheduled for elective coronary artery bypass grafting from May to October 2011, were randomized into two groups after the surgery. For the first group (group R, n=50, with mean age of 58.16±11.80), the IV-PCA protocol was remifentanil infusion 100 mg/h; bolus of 25 mg and lockout time of 15 minutes. In the second group (group P, n=50, with mean age of 53.8±15.08), patients received paracetamol 15 mg/kg as a bolus at the end of surgery and then IV-PCA protocol was 100 mg/h, bolus of 25 mg; and lockout time of 15 minutes. Pain was assessed with visual analog scale score (VAS) in the first 24 hours after surgery for seven times.Results: The trend of pain scores did not have any significantly difference between group R and group P except for hour 8 and hour 18 after surgery that VAS was significantly lower in group P than group R (P=0.031, P=0.023, respectively). Respiratory rate (RR) was also statistically lower in group R comparing to group P in all seven evaluating times. The groups were similar in terms of hemodynamic, ABG results (except for PaO2, which was significantly lower in group R than group P at 6 evaluating times), intubation time, renal function tests, and incidences of atelectasis, myocardial infarction or adverse effects.Conclusions: Both PCA techniques provided effective pain scores (<3) after cardiac surgery; but generally, PCA-paracetamol infusion has a better analgesic effect.

Dear Editor,Tonsillectomy remains one of the most frequent surgical procedures performed worldwide within ear, nose and throat (ENT) field. Despite significant improvements in anesthetic and surgical techniques, severe pains remain a major clinical problem after tonsillectomy (1, 2).

Background: The anti-inflammatory properties of magnesium sulfate have never been discussed in brain tumor surgeries. Objectives: This study is aimed to find anti-inflammatory aspects of high dose magnesium sulfate infusion during perioperative period of neurosurgical patients through checking the serial C-reactive protein (CRP) blood levels as a biomarker of inflammation. Patients and Methods: Sixty patients who were candidate for elective craniotomy were enrolled randomly into two equal groups to receive either magnesium sulfate or normal saline during their perioperative period. Infusion of magnesium was performed three times during the study and a summation of 15 grams was administered: 1- two days before surgery, 2- one day before surgery, 3- from the beginning of surgery (five grams was infused within six hours in each session). Serum level of CRP was checked just before commencement of magnesium infusion and on the first and second day after surgery as primary outcome. Hemodynamic parameters, total propofol requirement and total blood loss were recorded as well.Results: No significant difference was found between groups in terms of serum CRP levels. The mean arterial blood pressure, heart rate, blood loss and total anesthetic requirement were significantly lower in magnesium group in comparison to the control group.Conclusions: We did not find conclusive evidence for anti-inflammatory effects of magnesium in craniotomy for microsurgery of intracranial tumors using CRP level changes. However, high dose magnesium might be suggested as a safe anesthetic adjuvant in neurosurgery.

Background: Selection of anesthetic approach for lower extremity operations is often a controversial issue for anesthesiologists.Objectives: The aim of this study was to compare the incidence and severity of back pain between general and spinal anesthesia, and to find effective factors in developing postoperative back pain.Patients and Methods: In a randomized clinical trail, 148 patients with elective lower extremity surgeries were randomly allocated into two groups of 74. The first group received general anesthesia and the second group underwent spinal anesthesia. The incidence of back pain was observed and documented. The severity of back pain was assessed at the first, fourth and eighth postoperative weeks by visual analogue scale.Results: The mean of patients' age was 35.50±13.34 years. The incidence and mean of back pain severity among all participants were respectively 35.80% and 15.95% at the first week, 7.40% and 2.43% at the fourth week, and 1.4% and 0.27% at the eighth postoperative week. The incidence and mean of back pain severity in spinal group were respectively 39.2% and 18.11% at the first, 12.2% and 3.92% at the fourth, and 2.7% and 0.54% eighth postoperative weeks. In general anesthesia group, these figures were respectively 32.4% and 13.78% at the first week and 2.7% and 0.95% at the fourth postoperative week. No back pain was reported at the eighth postoperative week. The incidence and severity of back pain in the first week showed significant difference between the two groups, while the mean severity of back pain showed significant difference at the fourth week after operation.Conclusions: Spinal anesthesia could be probably considered as the sole effective factor in the development of back pain after operation.

Background: In clinical practice, the level of sensory block in spinal anesthesia in opium abusers is lower than that in non-abusers because of adaptive changes caused by opium use.Objectives: The aim of this study was to investigate the level of sensory block resulting from the intrathecal administration of 0.5% bupivacaine in opium abuser patients undergoing lower extremity and lower abdominal surgeries.Patients and Methods: A total of 100 patients who were candidates of elective lower extremity orthopedic and lower abdominal surgeries were recruited and assigned to two groups based on their history of opium addiction (Case or control). Both groups underwent the same anesthesia procedure and pinprick test was used to assess the level of anesthesia. Results: No statistically significant difference was observed between groups regarding age, duration of the surgery, and type of surgery. The frequency of addiction was higher in males than in females. The level of sensory block at three minutes was significantly lower in the opium abuser group (P=0.006). The mean time to achieve T10 sensory block was 10.33±5.79 minutes in the opium abusers and 6.89±3.88 minutes in the controls (P=0.001). The level of the highest sensory block was lower in the opium abuser group (P=0.002).Conclusions: The findings of this study suggested that after induction of spinal anesthesia with intrathecal administration of bupivacaine, chronic opium abusers would have a lower level of sensory block in comparison with patients without a history of opium abuse.

Background: Disk herniation (DH) is one of the most common disk lesions, inducing low back pain (LBP). Various therapeutic options have been proposed for treatment of disk herniation (DH). Intradiscal injection of ozone has been suggested for treatment of DH.Objectives: To determine the effect of intradiscal ozone injection on pain score and disability in patients with LBP from disk prolapsed.Patients and Methods: Patients with LBP diagnosed with DH were enrolled in this clinical trial study. After prep and drape the area and under the fluoroscopy guide (c-arm), intradiscal injection of ozone/oxygen mixture (4 mL, 40 mg/mL) was performed. Pain score and functional ability of the patients according to Oswestry Disability Index (ODI) were measured prior to the injection (baseline) and then at 2 and 4 weeks and then at 3 and 6 months after the injection.Results: Thirty patients (17 females, 13 males) with the mean age of 58.6 y (range, 42-73 y) enrolled in the study. The mean ± standard deviation (SD) of pain score before intervention was 8.1±0.8. After two weeks, it was reduced to 3.2±0.6 (P<0.001) and finally dropped to 2.0±0.6 sixth months after intervention (P=0.0001). Functional status of ODI was 28.5±2.1 before intervention and showed significant reduction after two weeks (with the mean of 12.3), and it was almost sustained till sixth months after intervention, with the mean of 11.4 (P=0.001).Conclusions: Altogether, ozone had significant positive effects on patients with disk herniation unresponsive to other conservative and minimally invasive treatments.

Background: One of the most expressed complains following coronary artery bypass graft (CABG) surgery is chest wall pain. Due to side effects of opioids used commonly for pain relief after heart surgeries, it is important to use low-cost and non-pharmacological methods independently or combined with palliatives to alleviate pain and consequently prevent undesirable drug adverse effects.Objectives: This study aimed to investigate the effect of Hazrate Zahra’s praises, which is one of the most known praises among Muslims in which the word “Allah” is repeated 100 times, on pain severity after CABG surgery.Patients and Methods: This randomized clinical trial study was performed on 80 patients in Busheher Bentolhoda Hospital, Iran, in 2013. Data was collected by a researcher-made questionnaire and Visual Analogue Scale (VAS). Patients were randomly assigned into intervention (n=40) and control (n=40) groups. In intervention group, we asked patients to recite Hazrate Zahra’s praises (AS) as one of the most known praises among Muslims in which the word “Allah” is repeated 100 times. In the control group, patients received routine procedures of hospital. Pain was assessed before and immediately after the intervention in three days after the operation in the both groups. Data was analyzed by SPSS 19 software using descriptive and analytic (Chi-square and independent and paired sample t test) statistical methods.Results: There was a significant difference regarding pain severity after the intervention between the two groups during three days after the operation (respectively P≤0.001, P≤0.001 and P≤0.003), but no significant difference was found between the two studied groups before the intervention. Moreover, a significant difference was seen before and after recitation in the intervention group during three days after the operation (for three days P≤0.001), while in control group no significant difference was revealed before and after the intervention (respectively P=0.493, P=0.541 and P=0.119).Conclusions: Reciting the word “Allah” as a non-pharmacological, low-cost and non-invasive method with no side effects can be effective on pain relief after CABG surgery.

Background: Pain relief after surgery is an essential component of postoperative care.Objectives: The purpose of this study was to compare the efficacy of intravenous acetaminophen and intravenous meperidine in pain relief after outpatient urological surgery.Patients and Methods: In a prospective, randomized, double-blind clinical trial, 100 outpatients of urological surgery were studied in two groups of acetaminophen (A) and meperidine (M). Patients in group A received 1g of acetaminophen in 100 mL saline within 15 minutes and patients in group M received a single intravenous injection of meperidine 0.5 mg/kg, 15 minutes prior to the end of operation. Postoperative pain was recorded using visual analog scale (VAS). Vital signs, nausea, vomiting, dizziness and respiratory depressions were compared between the two groups.Results: Pain severity in patients treated with intravenous acetaminophen six hours after the operation within one-hour interval was significantly lower than meperidine group (P<0.0001). Ninety patients in the meperidine group and five patients in the acetaminophen group required additional doses of analgesics. Nausea was significantly lower in acetaminophen group than meperidine group.Conclusions: Intravenous acetaminophen reduced pain following outpatient urological surgery more significantly than meperidine.