Anesthesiology and Pain Medicine
Year:2016 | Volume:6 | Issue:2|Papers Count:12

Dear Editor, Choosing an appropriate anesthesia machine for mechanical ventilation of pediatric patients is of paramount importance because small changes in the fractions of the delivered tidal volume can cause a significant difference from the desired tidal volume…

Background: Sepsis is the result of the interaction between inflammatory mediators and coagulation pathway. Unfractionated heparin may play a role as an anti-inflammatory agent beyond its anticoagulatory effect in sepsis. As a result, it may cause reduction in organ failure rate in patients with sepsis due to its impact on both inflammatory and coagulation process.Objectives: The aim of this study was to evaluate the anti-inflammatory effects of heparin in sepsis. Plasma plasminogen activator inhibitor-1 (PAI-1) as an inflammatory mediator and urinary necoutrophil gelatinase-associated lipocalin (NGAL) as a marker of kidney injury were investigated.Patients and Methods: This prospective, randomized controlled trial was conducted in a 32-bed intensive care unit. Thirty patients with sepsis were randomized to receive heparin infusion of 500 units/hour or 5000 units of heparin three times a day, subcutaneously.The plasma level of PAI-1 and urinary level of NGAL were determined at day 0, 2 and 7.Results: The infusion group had a lower plasma PAI-1 level compared to the subcutaneous group at day 7 (11.3  1.6 vs.16.5  4.2; P=0.003). The urinary NGAL level was lower in the infusion group at day 2 (131.3 11.9 vs.151.2  20.6; P=0.014); however, at day 7 the NGAL level was decreased in the subcutaneous group as much as the infusion group and there was no significant difference between the two groups. There was no significant difference in the acute physiology and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores between the two groups at day 0, 2 and 7.Conclusions: Low-dose heparin infusion compared to subcutaneous heparin can decrease the plasma PAI-1 and urinary NGAL levels more rapidly. It can be related to anti-inflammatory effects of heparin, which may be more prominent in infusion route.

Background: Sufentanil is a potent opioid analgesic frequently used in clinical anesthesia. Double-lumen endobronchial intubation induces profound cardiovascular responses in comparison with ordinary endotracheal intubation because of the larger tube diameter and direct irritation of the carina.Objectives: The purpose of this study was to determine the effective bolus dose of sufentanil to attenuate hemodynamic changes in response to laryngoscopic double-lumen endobronchial intubation.Patients and Methods: We randomly assigned 72 patients aged 18 - 65 years and with an American Society of Anesthesiologists physical status of 1 or 2 to one of four sufentanil dose groups: NS, S0.1, S0.2, or S0.3. The respective doses for the groups were as follows: normal saline, 0.1 mcg/kg of sufentanil, 0.2 mcg/kg of sufentanil, and0.3 mcg/kg of sufentanil. Blood pressure andheart rate were recorded during the pre-anesthesia period at baseline, pre-intubation, immediate post-intubation, and every minute during 5 minutes after intubation.Results: Baselinemeanarterial pressures in the NS, S0.1, S0.2, and S0.3 groups were 89.812.1, 89.210.9, 88.813.6, and 90.711.1, respectively. At immediate post-intubation, the mean arterial pressures in the NS, S0.1, S0.2, and S0.3 groups were 129.714.7, 120.7 14.2, 120.817.2, and 96.710.4, respectively. At immediate post-intubation, the mean arterial pressure in the NS, S0.1, and S0.2 groups significantly increased from baseline (P<0.001), but the S0.3 group showed no difference. In the time point comparison at immediate post- intubation, the S0.3 group had a significantly lower mean arterial pressure than did the NS, S0.1, and S0.2 groups (P<0.001).Conclusions: We found that 0.3 mcg/kg of sufentanil attenuates cardiovascular responses to double-lumen endobronchial intubation without adverse effects.

Background: Persistent postoperative pain (PPP) is defined as persistent pain after surgery of greater than three months’ duration.Objectives: Identify the incidence of PPP in our hospital and its associated factors; evaluate quality of life (QoL) and treatment of patients.Patients and Methods: We conducted an observational prospective study in adults proposed to various types of surgery using the brief pain inventory short form preoperatively (T0), one day after surgery, and three months later (T3). If the patient had pain at T3 and other causes of pain were excluded, they were considered to have PPP, and the McGill Pain Questionnaire Short Form was applied. QoL was measured with the Euro Qol 5-dimension questionnaire (EQ-5D).Results: One hundred seventy-five patients completed the study. The incidence of PPP was 28%, and the affected patients presented lower QoL. The majority referred to a moderate to severe level of interference in their general activity. Cholecystectomies were less associated with PPP, andtotal knee/hip replacements weremoreassociated with it. Preoperative pain, preoperative benzodiazepines or antidepressants, and more severe acute postoperative pain were associated with the development of PPP. Half of the patients with PPP were under treatment, and they refer a mean symptomatic relief of 69%.Conclusions: This study, apart from attempting to better characterize the problem of PPP, emphasizes the lack of its treatment.

A 78-year-old woman with burn-induced cervico-mento-sternal scar contracture was scheduled for laparoscopic cholecystectomy. During inhalational induction of sevoflurane, her airway patency deteriorated. The right lateral positionandassist ventilation using a breathing bag dramatically improved her airway patency.

Introduction: Pharmacologic treatment of radicular pain with oral medications is limited by adverse effects and concern for dependence.While topical formulations have been explored in pain research, there is no published literature evaluating the efficacy in radicular pain. We present the first three cases of radicular pain successfully treated with a topical formulation of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline (T7).Case Presentation: Case series evaluating T7 for treatment of radicular pain in a single, outpatient pain center. Pain was rated on the numeric rating scale (NRS) on initial evaluation and follow up after a trial of T7. One to two grams of T7 was applied to the affected area 3 - 4 times daily in addition to the patient’s baseline pharmacologic management. Three patients with median age of 50 (range, 39 to 65) and diagnosis of cervical and/or lumbosacral radicular pain participated. Two of the three had chronic radicular pain despite use of analgesic agents, spinal injections and failed spinal surgery syndrome. Each reported subjective improvement in radicular pain, function and sleep. There was an average decrease in NRS score consistent with 30% - 40% global improvement in symptoms, clinically significant based on the minimal clinically important difference for radicular pain. T7 was well tolerated without adverse reactions. Surgery was prevented or delayed in all cases.Conclusions: This is the first report of the successful treatment of radicular pain with a topical agent. This highlights the need for randomized, prospective study of both single and compounded topical agents for treatment of radicular pain.

Although efficient hospital and intensive care unit (ICU) throughput depends upon the expeditious admission and discharge of ICU patients (1), health care systems are facing ethical challenges of caring for complex patients that are known as multimorbidity (2-8). A vast majority of patients need ICU admission; furthermore, when hospital occupancy is near its full capacity, prompt discharge of ICU patients to ward beds may not be feasible…

Background: Many surgeries are performed under spinal anesthesia. Inexperienced practitioners may find it difficult to obtain subarachnoid access.Objectives: This study aimed to examine the relationship between patients’ anthropometric characteristics and depth of spinal needle insertion to the subarachnoid cavity.Patients and Methods: 385 patients with ASA class I – II, aged 18 - 65 years and undergoing elective surgery of the lower abdomen and extremities under spinal anesthesia, were selected for this cross-sectional study. The patients’ demographic characteristics, body mass index (BMI), and anthropometric characteristics (height, weight, waist circumference, and arm circumference) were recorded. Linear regression and t-student tests were used to study the relationship between anthropometric characteristics and BMI, and depth of needle insertion.Results: Of the 385 patients studied, 88 were female and 297 were male. There was a strong correlation between the depth of needle insertion and BMI (24.9 ± 3.9), and between depth and weight/height ratio (r = 0.95 and r = 0.92, respectively). There was no significant correlation between depth of needle insertion and weight, height, gender, or arm circumference, when considered separately. The statistical predicting models showed that the following relationship was observed between the needle depth and the weight/height ratio: A: needle depth = 0.69 + (10.1 × weight/height); B: needle depth = 0.56 + (0.18 × BMI).Conclusions: The results of this study show that there is a strong relationship between depth of needle insertion and BMI, and between depth and the weight/height ratio; appropriate depths can be determined according to the equations obtained.

Background: Failure to maintain an adequate airway can lead to brain damage and death. To reduce the risk of difficulty in maintaining an airway during general anesthesia, there are several known predictors of difficult intubation. People with a Malay background have different craniofacial structures in comparison with other individuals. Therefore, different predictors should be used for patients of Malay race.Objectives: The aim of this study was to determine the ability to predict difficult visualization of the larynx (DVL) in Malay patients based on several predictors, such as the modified Mallampati test (MMT), thyromental distance (TMD), and hyomental distance ratio (HMDR).Patients and Methods: This cross-sectional study included 277 consecutive patients requiring general anesthesia. All subjects were evaluated using theMMT, TMD, andHMDR, and the cut-off points for the airway predictors were Mallampati III and IV, <6.5 cm, and< 1.2, respectively. During direct laryngoscopy, the laryngeal view was graded using the Cormack-Lehane (CL) classification. CL grades III and IV were considered difficult visualization. The area under the curve (AUC), sensitivity, and specificity for each predictor were calculated both as sole and combined predictors. Logistic regression analysis was used to determine independent predictors of DVL.Results: Difficulty in visualizing the larynx was found in 28 (10.1%) patients. The AUC, sensitivity, and specificity for the three airway predictors were as follows: MMT: 0.614, 10.7%, and 99.2%; HMDR: 0.743, 64.2%, and 74%; and TMD: 0.827, 82.1%, and 64.7%. The combination providing the best prediction in our study involved the MMT, HMDR, and TMD with an AUC, sensitivity, and specificity of 0.835, 60.7%, and 88.8%, respectively. Logistic regression analysis showed that the MMT, HMDR, and TMD were independent predictors of DVL.Conclusions: The TMD, with a cut-off point of 65 mm, had superior diagnostic value compared with the HMDR and Mallampati score. Therefore, the TMD could be used in Malay patients to predict the difficulty of larynx visualization during laryngoscopy.

Background: Hemodynamic fluctuations in response to laryngoscopy and tracheal intubation and their potential hazards have been well-recognized, especially in hypertensive patients. Many drugs in various combinations have been used to attenuate these adverse responses.Objectives: We conducted a study to compare lidocaine with clonidine on the attenuation of hemodynamic responses to laryngoscopy and tracheal intubation, in controlled hypertensive patients undergoing general anesthesia.Patients and Methods: Eighty-six patients of American society of anesthesiologists (ASA) class II, who were aged 18 to 65-years-old and were scheduled for elective surgeries under general anesthesia, were included. The patients were randomly divided into two equal groups. The clonidine group received 0.2 mg oral clonidine 90 minutes before surgery and the lidocaine group received a placebo tablet at the same time. All patients in both groups were anesthetized with the same technique, including: intravenous fentanyl 3 mcg/kg, sodium thiopental 5 mg/kg, and atracurium 0.5 mg/kg. The lidocaine group received 1.5 mg/kg lidocaine but the clonidine group received the same volume of saline ninety seconds before intubation. Hemodynamic parameters were recorded before intubation and 1, 3, 5, and 10 minutes after endotracheal intubation.Results: There were no significant differences between the two groups’ hemodynamic parameters, including heart rate and systolic, diastolic, and mean arterial blood pressures at the measured points. There were also no significant differences within each group in hemodynamic responses at the measured points (P>0.05). Twenty patients in the clonidine and three patients in the lidocaine group complained of mouth dryness (P=0.001). Fourteen patients in the clonidine and four patients in the lidocaine group had bradycardia (P=0.008). Nineteen patients in the clonidine and six patients in the lidocaine group had orthostatic hypotension (P=0.002).Conclusions: There were no statistical differences between oral clonidine and intravenous lidocaine regarding attenuation of hemodynamic responses after tracheal intubation in controlled hypertensive patients, although the rate of complications including mouth dryness, bradycardia, and orthostatic hypotension was significantly higher in the clonidine group before induction of anesthesia.

Introduction: Sporadic inclusion body myositis (IBM) is an inflammatory myopathy characterized by progressive asymmetric extremity weakness, oropharyngeal dysphagia, and the potential for exaggerated sensitivity to neuromuscular blockers and respiratory compromise. The authors describe their management of a patient with IBM undergoing urgent orthopedic surgery.Case Presentation: An 81-year-old man with IBM suffered a left intertrochanteric femoral fracture after falling down stairs. His IBM caused progressive left proximal lower extremity, bilateral distal upper extremity weakness (left>right), and oropharyngeal dysphagia (solid food, pills). He denied dyspnea, exercise intolerance, and a history of aspiration. Because respiratory insufficiency resulting from diaphragmatic dysfunction and prolonged duration of action of neuromuscular blockers may occur in IBM, the authors avoided using a neuromuscular blocker. After applying cricoid pressure, anesthesia was induced using intravenous lidocaine, propofol, remifentanil followed by manual ventilation with inhaled sevoflurane in oxygen. Endotracheal intubation was accomplished without difficulty; anesthesia was then maintained using remifentanil and sevoflurane. The fracture was repaired with a trochanteric femoral nail. The patient was extubated without difficulty and made an uneventful recovery.Conclusions: In summary, there is a lack of consensus about the use of neuromuscular blockers in patients with IBM. The authors avoided these drugs and were able to easily secure the patient’s airway and maintain adequate muscle relaxation using a balanced sevoflurane-remifentanil anesthetic. Clinical trials are necessary to define the pharmacology of neuromuscular blockers in patients with IBM and determine whether use of these drugs contributes to postoperative respiratory insufficiency in these vulnerable patients.

Background: Etomidate is a potent hypnotic agent with several desirable advantages such as providing a stable cardiovascular profile withminimalrespiratory adverse effectsandbetterhemodynamicstabilitycomparedwith other induction agents. Thisdrug is associated, however, with myoclonic movements which is characterized by a sudden, brief muscle contractions as a disturbing side-effect.Objectives: The present study was designed to compare the effectiveness of low- dose midazolam, magnesium sulfate, remifentanil and low-dose etomidate to suppress etomidate-induced myoclonus in orthopedic surgery.Patients and Methods: A double-blind clinical trial study was conducted in an academic hospital from September 2014 to August 2015. Two hundred and eighty-four eligible patients, American society of anesthesiologists class I - II, scheduled for elective orthopedic surgery were randomly allocated into four equal groups (n=71). They received premedication with intravenous low-dose midazolam 0.015 mg/kg, magnesium sulfate 30 mg/kg, remifentanil 1mg/kg and low-dose etomidate 0.03 mg/kg two minutes before induction of anesthesia with 0.3 mg/kg intravenous etomidate. Then the incidence and intensity of myoclonus were evaluated on a scale of 0 - 3; 0=no myoclonus; 1=mild (movement at wrist); 2=moderate (movement at arm only, elbow or shoulder); and 3=severe, generalized response or movement in more than one extremity, within ninety seconds. Any adverse effect due to these premedication agents was recorded.Results: The incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group. The incidence rates of myoclonus were 51 (71.85%), 61 (85.9%), 30 (42.3%) and 41 (57.7%), and the percentages of patients who experienced grade III of myoclonus were 30 (58.8%), 32 (52.5%), 9 (30%) and 14 (34.1%) in the midazolam, magnesium sulfate, etomidate and remifentanil groups, respectively. The incidence and intensity of myoclonus were significantly lower in the low-dose etomidate group (P=0.0001). No notable adverse effect was detected in our patients during the study period.Conclusions: Intravenous etomidate 0.03 mg/kg prior to induction can effectively reduce the incidence and severity of myoclonus linked to etomidate.