Remifentanil versus dexmedtomidine for posterior spinal fusion surgery

Background: Controlling the hemodynamic situation of patients who have spinal operation is of prime importance, and maintaining the heart rate and blood pressure in normal or low- normal levels in these patients can reduce their bleeding loss. One of the commonly used drugs for this purpose is remifentanil. Another sedative-hypnotic-analgesic drug, with acceptable effects is dexmedetomidine. The aim of this study was to compare the effect of dexmedetomidine with remifentanil in spinal operation. Methods: In a double blind randomized clinical trial, using random sampling method, 60 patients with the age range of 15-65 years who were candidates for posterior spinal fusion operation were included. Induction of anesthesia was performed, and both groups received isoflurane 1 during the surgery. Remifentanil was injected via infusion pump in one group. The patients in the trial group received dexmedetomidine. As trial outcomes, heart rate and blood pressure were measured before, after induction and during the operation. Pain score, sedation score and the need to analgesic therapy were recorded in the recovery room and the ward. Independent sample t-test and chi-square were used for statistical analysis. Results: Dexmedetomidine had a significant lowering impact on intraoperative blood pressure and heart rate compared to remifentanil (p<0.001). The mean of sedation scores after extubation in patients who received dexmedetomidine was significantly higher than the sedation scores in patients who received remifentanil (p<0.001). The mean of post-extubation and recovery pain score in patients taking remifentanil was significantly higher than patients taking dexmedetomidine (p<0.05). Conclusion: Dexmedetomidine in patients with spinal operation is associated with lower postoperative pain score and intraoperative bleeding. Hemodynamic effects are significantly better in patients received dexmedetomidine

Success rate of airway devices insertion: Laryngeal mask airway versus supraglottic gel device

Background: The main important method for airway management during anesthesia is endotracheal intubation. Laryngeal mask airway (LMA) and supraglottic gel device (I-Gel) are considered alternatives to endotracheal tube. Objectives: This study sought to assess the success rate of airway management using LMA and I-Gel in elective orthopedic surgery. Patients and Methods: This single-blinded randomized clinical trial was performed on 61 ASA Class 1 and 2 patients requiring minor orthopedic surgeries. Patients were randomly allocated to two groups of LMA and I-Gel. Supraglottic airway placement was categorized into three groups regarding the number of placement attempts, i.e. on the first, second, and third attempts. Unsuccessful placement on the third attempt was considered failure and endotracheal tube was used in such cases. The success rate, insertion time, and postoperative complications such as bleeding, sore throat, and hoarseness were recorded. Results: In the I-Gel group, the success rate was 66.7 for placement on the first attempt, 16.7 for the second, and 3.33 for the third attempt. In the LMA group, the success rates were 80.6 and 12.9 for the first and second attempts, respectively. Failure in placement occurred in four cases in the I-Gel and two cases in LMA groups. The mean insertion time was not significantly different between two groups (21.35 seconds in LMA versus 27.96 seconds in I-Gel, P = 0.2). The incidence of postoperative complications was not significantly different between study groups. Conclusions: I-Gel can be inserted as fast as LMA with adequate ventilation in patients and has no major airway complications. Therefore, it could be a good alternative to LMA in emergency airway management or general anesthesia. © 2015, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM)

The Diagnosis of Vocal Cord Movement Impairment Using Ultrasonography: A Comparison of Transthyroid and Suprathyroid Views

Background: Iatrogenic recurrent laryngeal nerve (RLN) injury is an uncommon but serious iatrogenic complication, especially after head and neck surgeries, and some thoracic procedures. Laryngoscopy can be an invasive and uncomfortable procedure; therefore, the use of ultrasonography (US) as a noninvasive method of screening patients for impaired vocal cord mobility is desirable. This study was conducted to compare the visibility of vocal cords in 2 suggested US views: suprathyroid and transthyroid approaches. Methods: In this clinical trial, 144 patients of either sex, who were candidates for elective suchlike surgery, were enrolled. The participants underwent vocal cord US through transthyroid and suprathyroid windows in a transverse plane with and without water bath. The visibility of vocal cords in either view was graded from 1 (invisible) to 5 (clearly visible). Direct laryngoscopy was performed &nbsp;after surgeries, with anticipated risk of vocal cord dysfunction, in patients with suspicious or invisible vocal cords in US. Results: Symmetric movement of vocal cords was visible in 88.8% of the participants. The visibility of vocal cords in transthyroid view was better than the suprathyroid approach. The quality of sonographic views was better in females and in younger age groups. The application of water bath did not improve the overall visibility of vocal cords during US. Conclusions: Transthyroid US seem to be a valuable screening modality for anticipated vocal cord dysfunction. Application of this method, particularly in nonelderly women, conveys more favorable results. Future improvements in the ultrasound machines in the hands of well-trained clinicians will improve its diagnostic accuracy

Remote ischemic preconditioning in lower limb surgery; the hemodynamic and respiratory effects

Aim and Background: Remote Ischemic Preconditioning introduces brief episodes of ischemia and reperfusion which reduces long term ischemia in orthopaedic surgery. The aim of this study was to evaluate hemodynamic and respiratory effects of remote ischemic preconditioning in lower extremity orthopaedic surgeries.Methods: In this clinical trial 40 patients scheduled for lower extremity surgery with pneumatic tourniquet were randomly allocated to remote ischemic preconditioning (RIP group, n=20) and control group (n=19). Patients in RIP group received three “5 minutes” cycles of ischemia, alternating with 5 minutes of reperfusion before extended use of tourniquet. Hemodynamic variables prior to inflation of tourniquet, every 30 minutes during the surgery and 10 minutes after tourniquet deflation and also arterial blood gas sample prior to and after surgery were recorded and compared between groups.Results: During operation blood pressure dropped in the RIP group and variations in heart rate, respiratory rate and pulse oximeter measurements after surgical tourniquet release were not significantly different between two groups. Changes in blood gas parameters were significantly less pronounced in the RIP group.Conclusion: Remote ischemic preconditioning may not attenuate most of the adverse effects of surgical tourniquet deflation including variations in heart rate, respiratory rate and arterial oxygen saturation as well as blood pressure drops. However, RIP may reduce increases in systolic blood pressure and acidosis following tourniquet application.Key Words: Remote Ischemic Preconditioning; Orthopedic, surgery, blood pressure, tourniquet, oxygenatio

The effect of different doses of intrathecal hyperbaric bupivacaine plus sufentanil in spinal anesthesia for cesarean sections

Background: Decreasing side effects and improving the quality of block in caesarean sections by appropriate dosage of local anesthetics and adjuvants could play an important role in the safe management of cesarean section. The present study aimed at comparing the effects of 3 different doses of intrathecal hyperbaric bupivacaine injected with a fixed dose of sufentanil in cesarean sections. Methods: In a double- blind randomized clinical trial, 105 candidates of elective cesarean section were randomly assigned into 3 groups of 8, 9, and 10 mg of intrathecal bupivacaine plus sufentanil 2.5 µg. The maximum level of sensory block, the intensity of motor block, and vital signs were measured at regular intervals. The incidence of hypotension and bradycardia were also recorded. Results: No significant difference was found between the maximum level of sensory block and the intensity of motor block in 3 groups. The incidences of hypotension and bradycardia as well as administration of atropine and ephedrine were comparable among the 3 groups (P > 0.05). Conclusions: According to similar effects of different doses of bupivacaine, administration of lower doses of bupivacaine (8mg) is more reasonable for spinal anesthesia for cesarean section. © 2017, Anesthesiology and Pain Medicine

Analgesic effects of paracetamol and morphine after elective laparotomy surgeries

Background: Opioids have been traditionally used for postoperative pain control, but they have some unpleasant side effects such as respiratory depression or nausea. Some other analgesic drugs like non-steroidal anti-inflammatory drugs (NSAIDs) are also being used for pain management due to their fewer side effects. Objectives: The aim of our study was to compare the analgesic effects of paracetamol, an intravenous non-opioid analgesic and morphine infusion after elective laparotomy surgeries. Patients and Methods: This randomized clinical study was performed on 157 ASA (American Society of Anesthesiology) I-II patients, who were scheduled for elective laparotomy. These patients were managed by general anesthesia with TIVA technique in both groups and 150 patients were analyzed. Paracetamol (4 g/24 hours) in group 1 and morphine (20 mg/24 hours) in group 2 were administered by infusion pump after surgery. Postoperative pain evaluation was performed by visual analog scale (VAS) during several hours postoperatively. Meperidine was administered for patients complaining of pain with VAS > 3 and repeated if essential. Total doses of infused analgesics, were recorded following the surgery and compared. Analysis was performed on the basis of VAS findings and meperidine consumption. Results: There were no differences in demographic data between two groups. Significant difference in pain score was found between the two groups, in the first eight hours following operation (P value = 0.00), but not after 12 hours (P = 0.14).The total dose of rescue drug (meperidine) and number of doses injected showed a meaningful difference between the two groups (P = 0.00). Also nausea, vomiting and itching showed a significant difference between the two groups and patients in morphine group, experienced higher levels of them. Conclusions: Paracetamol is not enough for postoperative pain relief in the first eight hour postoperatively, but it can reduce postoperative opioid need and is efficient enough for pain management as morphine after the first eight hours following surgery. © 2014, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM)

Comparison effect of pre-emptive gabapentin and oxycodone on pain after abdominal hysterectomy: A double blind randomized clinical trial

Gabapentin is popular analgesic adjuvants for improving postoperative pain management. The aim of this study was to compare the preventive effects of pre-emptive oxycodone and gabapentin on acute pain after elective abdominal hysterectomy. One hundred patients undergoing abdominal hysterectomy were randomly assigned to oxycodone group received 10 mg of oxycodone and gabapentin group received 10 mg of gabapentin 1 hour before surgery. The anesthetic technique was standardized, and the postoperative assessments included the amount of meperidine consumption, PONV and VAS for postoperative pain at arrival to recovery, 6, 12 and 24 h after surgery. Bleeding loss assessed during surgery. Postoperative pain scores were significantly lower in the gabapentin group compared with the oxycodone group. (P=0.0001) The total meperidine used in the gabapentin group was significantly less than in the oxycodone group. Postoperative nausea and vomiting (PONV) and blood loss during surgery were significantly decreased in gabapentin group. Based on the results of this study, Pre-emptive use of gabapentin 1200 mg orally, significantly decreases postoperative pain and PONV, rescues analgesic requirements and also bleeding loss during surgery in patients who undergo abdominal hysterectomy. Significant side effects were not observed. © 2018 Tehran University of Medical Sciences. All rights reserved

Comparison effect of pre-emptive gabapentin and oxycodone on pain after abdominal hysterectomy: A double blind randomized clinical trial

Gabapentin is popular analgesic adjuvants for improving postoperative pain management. The aim of this study was to compare the preventive effects of pre-emptive oxycodone and gabapentin on acute pain after elective abdominal hysterectomy. One hundred patients undergoing abdominal hysterectomy were randomly assigned to oxycodone group received 10 mg of oxycodone and gabapentin group received 10 mg of gabapentin 1 hour before surgery. The anesthetic technique was standardized, and the postoperative assessments included the amount of meperidine consumption, PONV and VAS for postoperative pain at arrival to recovery, 6, 12 and 24 h after surgery. Bleeding loss assessed during surgery. Postoperative pain scores were significantly lower in the gabapentin group compared with the oxycodone group. (P=0.0001) The total meperidine used in the gabapentin group was significantly less than in the oxycodone group. Postoperative nausea and vomiting (PONV) and blood loss during surgery were significantly decreased in gabapentin group. Based on the results of this study, Pre-emptive use of gabapentin 1200 mg orally, significantly decreases postoperative pain and PONV, rescues analgesic requirements and also bleeding loss during surgery in patients who undergo abdominal hysterectomy. Significant side effects were not observed. © 2018 Tehran University of Medical Sciences. All rights reserved

Fluid loading therapy to prevent spinal hypotension in women undergoing elective caesarean section Network meta-analysis, trial sequential analysis and meta-regression

BACKGROUND Fluid loading is one of the recognised measures to prevent hypotension due to spinal anaesthesia in women scheduled for a caesarean section. OBJECTIVE We aimed to evaluate the current evidence on fluid loading in the prevention of spinal anaesthesia-induced hypotension. DESIGN Systematic review and network meta-analysis with trial sequential analy

The Relationship Between Changes in Liver Enzymes and Mortality of Patients Admitted to a Surgical Intensive Care Unit

Background: Increased levels of alanine transaminase (ALT) and alkaline phosphatase in the liver are associated with an increased risk of mortality in hospitalized patients. This study aimed to survey the relationship between changes in liver enzymes and mor[1]tality of patients admitted to a surgical intensive care unit (ICU). Methods: This cross sectional study was based on the electronic and clinical records of patients, hospitalized in the ICU of Rasool Akram hospital from 2012 to 2015. The information of 199 alive and 140 deceased patients was studied. The laboratory parameters, clinical information, acute physiology and chronic health evaluation (APACHE-II) scores, and sequential organ failure assessment (SOFA) scores were determined upon admission, and length of ICU stay was measured. Results: There was a significant difference in the aspartate aminotransferase (AST) level upon admission in alive and deceased groups (42.01 ± 46.65 and 58.54 ± 80.95 mg/dL, respectively) (P &lt; 0.05). However, there was no significant difference in the level of AST at discharge between the groups (39.05±36.69 and 67.95±21.7mg/dL, respectively) (P &gt; 0.05). There was a significant difference in the level of ALT upon admission between the groups (34.21±58.13 and 41.32±66.77mg/dL, respectively) (P &gt; 0.05). However, there was no significant difference in ALT level at discharge between the groups (38.44 ± 48.69 and 42.94 ± 76.47 mg/dL, respectively) (P &gt; 0.05). Based on the multivariate logistic regression model, the predictive factors for mortality included use of inotropes, alkaline phosphatase, and reduced platelet count, potassium level, and heart rate. Conclusions: Measurement of serum liver enzymes has inadequate predictive value for mortality in ICU patient