JOURNAL OF IRANIAN SOCIETY ANAESTHESIOLOGY AND INTENSIVE CARE
Year:2009 | Volume:31 | Issue:67|Papers Count:12

Background: spinal Anesthesia is very common in ceasarean section and post spinal headache is the most important complication of it. The aim of this study is evaluation of post spinal headache in median and paramedian approach of spinal Anesthesia.Materials and Methods: In a randomized double blind clinical trial 125 patients with ASA Class I, II scheduled for elective ceasarean section received spinal anesthesia with median or paramedian approach. The needle, drug and anesthesiologist were the same in both groups. Headache was evaluated for three days following surgery. Results: The incidence of headache was 9.8% in paramedian group versus 9.4% in median group (statistically not significant) changes in blood pressure, heart rate and necessity of ephedrine usage was not statistically significant.Conclusion: Use of paramedian approach in pregnant women who have difficulty in positioning is acceptable and without increasing risk of headache and hemodynamic changes.

Background: Acute postoperative pain management is challenging in patients with preoperative narcotic dependency. Opioids are cornerstone drugs for this purpose, but even large doses of opioids to these patients do not always provide adequate postoperative analgesia. Therefore, some adjuvant drugs were administrered to provide sufficient analgesia. This prospective randomized study was designed to assess analgesic effect of added chlorpromazine, promethazine and midazolam as adjuncts to IV patient-controlled analgesia (PCA) morphine for postoperative pain management in opioid tolerant patients. Materials and methods: Eigthy opioid tolerant patients candidated for postoprative pain management by PCA were divided in two groups (M and P groups). The patients were started on PCA with a 5 ml/h basal infusion and the daily drug administration in M group was morphine 40 mg, and in P group was chlorpromazine 50 mg, promethazine 50 mg, and midazolam 10 mg added to morphine 20 mg. Visual analogue pain scale (VAS), sedation score, average morphine administrered, and side effects were evaluated for 72 hours. Statistic analysis was done by Friedmann, Chi- square, Kruskal-Wallis and Mann-Whitney U tests.Results: Demographic data were not differences between two groups. The pain score in M group was more than P group (3.2±1.8 vs 2.4±1.2) (p<0.05). Furthermore, sedation score was lower in group M than P group (1.2±0.3 vs 2.3±0.4) that the difference was significant (p<0.05). Although, the average additional morphine consumption was not different between two groups (21±8.5 vs 20.5±6.5 mg), the total morphine administered was significantly higher in M than P group (140±15.9 vs 81.2±12.6 mg) (p<0.01). There were not observed any considerable side effects in both groups.Conclusion: In opioid tolerant patients, combination of chlorpromazine, promethazine and midazolam added to PCA morphine caused better postoperative analgesia and lower analgesics requirement.

Background: Hypothermia frequently accompanies general and regional anesthesia and can be associated with adverse postoperative outcomes including wound infection, coagulopathy, morbid cardiac events as well as reduction of drug metabolism and shivering. Surgical patient become hypothermic because of redistribution of heat within the body due to anesthetic-induced vasodilation and as a result of exposure to a cold operating environment, instillation of cool fluids into body cavities and inhibition of thermoregulatory response by anesthetics. In addition, intravenous infusion of cold blood or room temperature fluids aggravates hypothermia. Thus, prevention of perioperative hypothermia should be considered seriously. The goal of this study was to assess the effect of intravenous infusion of room temperature crystalloid solution on the core and the surface body temperatures prior to administration of regional anesthesia.Materials and methods: This prospective descriptive and cross sectional study was performed on eighty healthy pregnant women who were scheduled for elective cesarean section under regional anesthesia. In the operating room, before administration of anesthesia, patient's core and skin temperatures as well as temperature of the intravenous fluids were measured. Then 10ml/kg room temperature ringer solution was infused rapidly (10ml / kg / 15min) and body temperatures were re-evaluated subsequently. Results: Age of patients was 28.37±4.07 years (range: 20 to 37 years) and temperature of intravenous ringer solutions was 23.48±0.08°c. Patients' core and skin body temperatures significantly reduced after rapid infusion of fluids by 0.5 ± 0.12°c and 0.6±0.31°c, respectively (p=0.001).Conclusion: Infusion of room temperature intravenous fluids result in the occurrence of perioperative mild hypothermia.

Background: Tizanidine is a clonidine derivative and 2-adrenoreceptor agonist that has the same effects (sedation, anxiolysis and analgesia) but lesser side effects (hypotension and bradycardia). In these study effects of oral tizanidine on post operative pain was evaluated.Materials and methods: In this clinical trial double blind study sixty patients (ASA I, II), aged 18-60yr, were randomly allocated into two groups. 90 minutes before induction of anesthesia both control and tizanidine group received placebo and 4mg oral tizanidine respectively. Pain severity and sedation score were assessed before and after receiving placebo or tizanidine and in the first 24hr post operative period, meperidine requirements were assessed.Results: Pain severity and meperidine requirements in the tizanidine group was significantly lower than that in the control group (p<0.001). Sedation score was significantly higher than that in the tizanidine group (p<0.001). Conclusion: It was possible to reduce the post operative pain by oral administration of 4 mg tizanidine as premedication. Therefore, we recommended premedication with tizanidine for patients undergoing surgery.

Background: Use of opioids in spinal anesthesia is becoming increasingly popular in caesarian section. Opioids but however increase vomiting, nausea and itching reactions. We compared intrathecal use of either fentanyl or sufentanyl in cesarean section with respect to side effects during block and 24 hours later. We also compared duration of effective analgesia and pain intensity among study groups. Materials and methods: During this prospective double blind clinical study, 129 pregnant patients ASA Class l and ll, admitted for cesarean section at Emam Khomeini Hospital, Ahwaz. Patients were randomly assigned into 3 groups, 43 in each grouop. Patients had spinal anesthesia using 60 mg lidocaine with either 25 microgram fentanyl or 5 microgram sufentanil or equal volume of normal saline. Patients were followed up for incidence of vomiting, nausea and pain intensity for a period of 24 hours. Results: Patients in control group had mean analgesia time of 72±3.7 min, compared to 97.8± 4.2 min in sufentanyl group and 99±2.3 min in fentanyl group (p <0.05). Mean VAS scores was 4.58±.82 in control group compared to 4.51±1.8 and 3.25±0.81 in fentanyl and sufentanyl groups respectively. Patients in fentanyl group had highest rate of nausea and vomiting, during operation and on post op period. The difference was significantly higher than control group, but it was not significantly different from sufentanyl group.(p<0.05) Itching was not significantly different between all groups (p>0.05). Conclusion: According to statistical data analysis, intrathecal fentanyl and sufentanil can increase duration quality of analgesia during and in post op. in cesarean section. Side effects such as itching and respiratory depression are infrequent. Higher incidence of nausea and vomiting is seen with both fentayl and sufentanil which is probably easily correctable with anti emetics.

Background: The colles fracture is always accompanied by a severe pain when the physician tries to reduce it. Hematom block is one of the regional aesthetic techniques that used to anesthetize the patient.especialy in the population with age related problem that accompanies with high risk anaesthesia. Materials and methods: 80 patients 45-65yr old with ASA physical status I or III requesting hematom block were randomized into two groups, with or without bicarbonate addition to lidocaine in closed reduction of colles fracture, respectively. The patients were sedated with midazolam 0.15 mg/kg and fentanyl 1mic/kg for both groups. In B group and A group the patient were anesthetized by 9 ml lidocaine 2% and 1ml bicarbonate 7.5% and 9 ml lidocaine 2% and 1ml water solution respectively. After alternative injection and aspiration into the fracture area, all samples were studied in terms of onset of anesthesia and its quantity of pain by visual analogue score (VAS) before, during and thirty minutes after reduction. The data was gathered using a checklist and analyzed by SPSS software through descriptive statistics and Chi two paired T test & X2. Statistical significance required P < 0.05 (P <0.05).Results: The study showed that onset of analgesia in B group (H. block with bicarbonate) with (388.2±63.8sec) and in groups A (H. block without bicarbonate) with (469.2±32.2sec) respectively (p=0.0001).VAS in the starting time of injection in B group with (7.9±1.9) and in A group (7.5±0.93) respectively (p=.069). Also, VAS during manipulation in B group was (1.4±0.75) and in A group (1.8±0.83) respectively (p=0.029). Eventually, thirty minutes later VAS scores of (4±0.81) in B group and in A group (4.7±0.88) respectively (p=0.001).Conclusion: Bicarbonate addition to lidocaine as an additive agent has a great effect on acceleration of anesthesia with reduction of post operative pain score. So hematoma-block with bicarbonate additive is recommended for this kind of fracture.

Background: Laryngoscopy and tracheal intubation have often been associated with increased blood pressure and heart rate. One of the proposed methods for reducing these changes is to use fiberoptic bronchoscope for tracheal intubation. In the present study hemodynamic changes after fiberoptic intubation has been compared with laryngoscopic method in hypertensive patients.Materials and methods: 94 hypertensive patients who have not received antihypertensive medication for at least 10 days randomly allocated in two groups and were anesthetized in same manner. Intubation in one group was performed with fiberoptic bronchoscope and in the other group by laryngoscope. Hemodynamic parameters including heart rate, systolic and diastolic blood pressure were recorded before induction (baseline), before intubation and 2, 4 and 6 minutes after intubation. Results: Heart rate at 2 minutes and diastolic blood pressure at 4 minutes after intubation in the fiberoptic group and systolic blood pressure at 6 minutes after intubation in the laryngoscopy group were significantly higher than the other group. Comparison of the data obtained after intubation with preintubation values revealed a significant rise except for diastolic blood pressure and heart rate at 6 minutes in the fiberoptic group.Conclusion: The findings of this study reveal that the hemodynamic change at the early moments of intubation is more prominent with the fiberoptic method while its duration is shorter than laryngoscopic intubation. It seems that the fiberoptic bronchoscopy can not help more in attenuation of hemodynamic reflexes to intubation in hypertensive patients.

Introduction: Intrathecal injections are one of the available modalities for patient s pain relief. This study assessed the efficacy of analgesic property of a benzodiazepine (midazolam; with approved analgesic effect when administered intrathecally, IT) against an opioid (fentanyl; an analgesic drug without any local anesthetic properties when used IT). Based on previous studies, midazolam has less side effects on hemodynamics and respiratory systems in contrast with other drugs used intrathecally for pain relief. Materials and Methods: This survey has been done as a randomized clinical trial in 60 patients with lower limbs fractures (below the knee; within 24 hrs of injury) referred to hospitals of Imam Hossein and Loghmanaldoleh (acute pain). Based on the inclusion criteria, patients were divided randomly into M group (midazolam used IT) or F group (fentanyl used IT). The intrathecal (IT) injection was done after the primary evaluations of patient’s vital signs, receiving intravenous fluids and determining the acute pain score in each group based on VAS scores. After 15 minutes of injection, the patients new pain score were assessed again as previous. All patients underwent the general anesthesia on a predetermined protocol. All the surgical procedures were done in less than 2 hours.Results: It was shown in this study that injection of midazolam IT is significantly more effective in acute pain relief than fentanyl does as the acute pain score reduction in M group was 3.06±1.617 while in F group was 1.46±0.507 (p-value<0.001). The pain-free time (VAS<4) duration after the surgical procedure in the ward was significantly more for the midazolam group [for midazolam was 7:15 (CI. 95%: 6.6-7.8) and for fentanyl group was 3:30 (CI. 95%:3.3-3.7)].Conclusion: Acute pain was relieved more effectively in patients when midazolam used IT (4mg) in comparison with fentanyl (40μg). More studies are needed to assess more analgesic properties of IT midazolam and it s therapeutical considerations in the other types of pain (chronic, neuropathic, etc.).

Introduction: Pseudoaneurysm is caused by internal tearing of wall of the aorta due to trauma, previous surgery or infectious disease of the aorta. Cerebrovascular accidents are serious complications of surgical repair of pseudoaneurysm that is due to cerebral hypoperfusion; air, clot, or atheromatous emboli and subsequent cerebral ischemia.Report: The patient is a 56 years old man that is monitored with cerebral oximetry during surgical repair of a pseudoaneurysm of ascending aorta and desaturation of his brain was noted and he suffered from right hemiplegia after surgery.Conclusion: Cerebral oximetry is a useful monitoring of cerebral oxygen saturation during cardiovascular surgery and can help in detection of cerebral ischemia and prevention of postoperative neurologic complications.