Reduction of intraoperative bleeding with fibrinogen administration in posterior spinal fusion surgery

Background: Spinal surgeries are frequently complicated with high rate of intra- and post-operative hemorrhage. It is shown that the serum fibrinogen level is a pivotal factor in determining the degree of intra- and post-operative hemorrhage. This study sought to examine the effect of prophylactic infusion of fibrinogen in preventing hemorrhage in candidates for posterior spinal fusion surgery. Methods: 41 patients who were candidates for posterior spinal fusion surgery were randomly devided in two groups of intervention (21 patients) and control (20 patients), receiving either infusion of fibrinogen (1 g in 100 cc of normal saline infused within 5 minutes after induction) or placebo, respectively. Changes in serum hemoglobin and fibrinogen, the severity of intraoperative hemorrhage, and the need for blood transfusion were compared between the two groups. Findings: While pre- and postoperative changes in serum hemoglobin and fibrinogen did not differ significantly between the two groups, the mean blood loss (533.3 ± 157.9 vs. 679.0 ± 130.0 ml, P = 0.003) and the need for blood transfusion (0 vs. 30 percent, P = 0.030) were significantly higher in the control group. Conclusion: Prophylactic infusion of fibrinogen in candidates for posterior spinal fusion surgery may significantly decrease the amount of intra-operative hemorrhage and the need for blood transfusion. © 2015, Isfahan University of Medical Sciences(IUMS). All Rights Reserved

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)

Anesthetic management for lower limb fracture in severe aortic valve stenosis and fat embolism: A case report and review of literature

Introduction: Anesthesia in severe aortic stenosis, which describes a valve surface area less than 1 cm2, can result in rapid clinical deterioration and patient mortality. These patients may require treatment for aortic stenosis before any surgical intervention. In suitable patients percutaneous balloon aortic valvutomy appears to carry lower risk, but in emergency situations, it is important to determine which kind of anesthesia technique has the lowest risk for these patients, without any cardiac intervention. Case Presentation: In this case report, we present a patient who had tibia and fibula fractures and a symptomatic severe critical aortic stenosis which was diagnosed during a preoperative visit. The patient had exertional dyspnea, palpitations and fainting history, but he had not received any medical therapy before the present admission. During hospitalization and preoperative evaluation, a fat embolism occurred and the patient was admitted to the intensive care unit. Immediately after his recovery, we successfully managed the tibia and fibula fracture fixation without any cardiac intervention. Conclusions: Our anesthesia method was sciatic and femoral nerve block under double ultrasonic and nerve stimulator guidance. © 2014, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar Corp

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)

Evaluation of intranasal dexmedetomidine in providing moderate sedation in patients undergoing ERCP: A randomized controlled trial

Background and purpose: Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed under deep sedation. Respiratory depression and airway obstruction are the most dangerous complications of sedatives. Dexmedetomidine is a drug that does not cause respiratory depression so, this study evaluated the efficacy of nasal dexmedetomidine in inducing moderate sedation in patients undergoing ERCP. Materials and methods: In a double blind randomized controlled trial, the patients candidate for ERCP in Firoozgar hospital, were divided into two groups. Group I received normal saline while in group II dexmedetomidine 1μg/kg was administered intranasaly. Also, intravenous midazolam and fentanyl, and if needed, propofol were used for induction of sedation. Then total use of sedative drugs, hemodynamic parameters, patient and physician satisfaction and side effects of treatment were documented. Results: There were no significant differences in age, sex and BMI between the two groups. Mean use of midazolam and fentanyl was almost similar in two groups but the use of propofol was lower in group II (P= 0.002). The mean heart rate was found to be lower in the group receiving dexmedetomidine but systolic and diastolic blood pressure were almost similar in two groups (P> 0.05). Compared with the results in group I, the patients and physicians in group II were more satisfied with dexmedetomidine. Conclusion: Dexmedetomidine as an adjuvant drug for sedation in patients undergoing ERCP could reduce the need for other sedatives, and also satisfy both the patients and therapists. © 2016, Mazandaran University of Medical Sciences. All Rights reserved

Controlled hypotension during rhinoplasty: A comparison of dexmedetomidine with magnesium sulfate

Objective: The current study aimed at comparing the efficacy of dexmedetomidine and magnesium sulfate to control blood pressure (BP) during rhinoplasty and the resultant effects on the quality of surgical field in terms of bleeding and visibility. Methods: The current randomized, prospective, double-blind study was conducted on 60 patients aged 18 to 50 years classified as ASA (American Society of Anesthesiologists) physical status I who were candidates for rhinoplasty. Patients were randomly divided into 2 groups: (1) group Dex, received 1 µg/kg dexmedetomidine in 10 minutes before induction of anesthesia, followed by 0.4 - 0.6 µg/kg/hour during the maintenance of anesthesia, and (2) group Mg, received 40 mg/kg in 10 minutes before anesthesia induction followed by 10 - 15 mg/kg/hour during anesthesia maintenance. In both groups, the goal was to achieve a mean arterial pressure (MAP) of 60 - 70 mmHg. Hemodynamic variables, anesthetic, opioid, muscle relaxant requirements, and surgical field condition were recorded. Sedation score, time to reach modified Aldrete score � 9, and adverse effects including nausea and vomiting (N&V) and shivering were recorded. Results: Controlled hypotension was achieved in both groups. There was no significant difference in MAP between the groups, but heart rate (HR) was significantly lower in the Dex group (P < 0.001), compared with that of the Mg group. Bleeding score was lower (P < 0.001) and surgeon�s satisfaction score was higher (P < 0.001) in the Dex group. More patients required fentanyl (P < 0.001) or nitroglycerin (P < 0.001) and the mean fentanyl (P = 0.005) or nitroglycerin (P < 0.001) required doses were higher in the Mg group. Patients in the Dex group required more frequent administration of cisatracurium (P = 0.004). Five patients in the Dex group versus no patients in the Mg group received atropine (P = 0.023). Ramsay sedation score and time to reach modified Aldrete score � 9 were significantly higher in the Dex group (P < 0.001 and P < 0.001, respectively). The incidence rate of N&V and shivering were similar in both groups. Conclusion: Dexmedetomidine was more effective than magnesium to achieve controlled hypotension, and provide a favorable surgical field condition. However, dexmedetomidine also heightened the risk of induced bradycardia and prolonged sedation. These are 2 important points to consider when applying this drug as a hypotensive agent during operation. © 2017, Anesthesiology and Pain Medicine

Comparing the effect of adaptive support ventilation (ASV) and synchronized intermittent mandatory ventilation (SIMV) on respiratory parameters in neurosurgical ICU patients

Background: Various modes of mechanical ventilation have different effects on respiratory variables. Lack of patients� neuroventilatory coordination and increasing the work of breathing are major disadvantages in mechanically ventilated patients. Objectives: This study is conducted to compare the respiratory parameters differences in Adaptive support ventilation (ASV) and synchronized intermittent mandatory ventilation (SIMV) modes in neurosurgical ICU patients. Methods: In a crossover study, patients under mechanical ventilation in neurosurgical ICU were enrolled. The patients alternatively experienced two types of ventilations for 30 minutes (adaptive support ventilation and synchronized intermittent mandatory ventilation). The respiratory parameters (tidal volume, respiratory rate, airway pressure, lung compliance, end-tidal carbon dioxide, peripheral oxygenation and respiratory dead space), hemodynamic variables, every 10 minutes and arterial blood gas analysis at the end of each 30 minutes were recorded. Results were compared and analyzed with SPSS v.19. Results: Sixty patients were involved in this study. In ASV mode, values including peak airway pressure (P-peak), end-tidal carbon dioxide (EtCO2), tidal volume and respiratory dead space were significantly lower than SIMV mode. Although the mean value for dynamic compliance had no significant difference in the two types of ventilation, it was better in ASV mode. Conclusions: ASV mode compared with SIMV mode can lead to improve lung compliance and respiratory dead space. © 2016, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM)

Effect of intraperitoneal bupivacaine on postoperative pain in laparoscopic bariatric surgeries

Background: Postoperative pain has many adverse effects and, if not properly controlled, it may lead to a wide range of complications. Opioids, as frequently used drugs for pain control, have some serious respiratory and gastrointestinal complications, especially in obese patients. Objectives: In this study, we planned to evaluate the effect of intraperitoneal bupivacaine lavage on postoperative pain in laparoscopic bariatric surgeries. Setting: The study was conducted in Firoozgar Hospital (affiliated to Iran University of Medical Sciences), Tehran, Iran. Methods: In this clinical trial, 106 patients scheduled for laparoscopic bariatric surgery, randomly assigned to receive either intraperitoneal lavage with 50 mL of .2 bupivacaine or the same volume of normal saline during the operation. One-gram intravenous paracetamol was infused for all patients at the end of surgery, and all patients received intravenous paracetamol infusion for 1 day after surgery. Pain level, assessed by visual analog scale, was recorded at 1, 4, 8, and 24 hours after surgery. Total additive analgesics administered during the first day after surgery was also recorded. Results: The pain score during the first 24 hours after surgery decreased significantly in both groups, but comparing the groups showed that pain level at 1, 4, 8, and 24 hours after surgery in the bupivacaine group was significantly lower than the normal saline group (P < .05). Also, opioid consumption during 24 hours was significantly lower in the bupivacaine group (P < .001). Conclusions: Intraperitoneal lavage with bupivacaine is an effective approach to control postoperative pain in obese patients undergoing laparoscopic bariatric surgery. © 2019 American Society for Bariatric Surger

Remifentanil infusion during emergence moderates hemodynamic and cough responses to the tracheal tube: A randomized controlled trial

Objective To examine the severity of cough and straining at the time of emergence from anesthesia. Design Double-blind randomized, placebo-controlled study. Setting University-affiliated hospital. Patients Sixty-two American Society of Anesthesiologists 2 patients undergoing craniotomy and excision of supratentorial cerebral tumors. Intervention Intravenous infusion of remifentanil (REM) at 0.05 μg/kg/min or normal saline (NS) upon termination of the surgical procedure. Measurements Heart rate (HR) and mean arterial pressure (MAP) along with the frequency and severity of cough response (Modified Minogue Scale) to the endotracheal tube were recorded at different time points. The frequency of cough and straining was analyzed with �2 tests. HRs and MAP were analyzed by repeated-measures analysis of variance between REM and NS groups. Main Results There was no case of significant cough in the REM group, and all of the patients in the NS group developed some extent of cough varying from mild retching to severe coughing episodes (P &lt;.001). Both the HR and MAPs were consistently lower in the REM group compared to the NS group. Conclusion Infusion of REM at the end of craniotomy procedures results in significant reduction of the frequency and severity of coughing and straining. Compared to placebo, REM moderates increases in MAP upon emergence from general anesthesia until the time of extubation. © 201

A clinical trial of volume- versus pressure-controlled intraoperative ventilation during laparoscopic bariatric surgeries

Background: Intra-operative ventilation is often challenging in patients with morbid obesity undergoing bariatric surgery. Objectives: To test the noninferiority of pressure-controlled ventilation (PCV) to volume-controlled ventilation (VCV) in respiratory mechanics. Setting: Bariatric Surgery Center, Iran. Methods: In a randomized open-labeled clinical trial, 66 individuals with morbid obesity undergoing laparoscopic bariatric surgeries underwent intraoperative ventilation with either PCV or VCV. The measurements taken were peak and mean airway pressures (H2O), partial pressure of arterial oxygen (PaO2), partial pressure of arterial carbon dioxide (PaCO2) and end-tidal carbon dioxide (CO2). We additionally collected pulse-oximetric oxygen saturation, inspiratory concentration of oxygen (FiO2), and hemodynamic variables. Data were analyzed with repeated measures over the time of intubation, after peritoneal insufflation, and every 15 minutes, thereafter up to one hour. Results: PCV mode was successful to sustain adequate ventilation in 97 of the patients, which was similar to the 94 success rate of the VCV mode. Peak airway pressure increased 6 cmH2O and end-tidal CO2 rose by 5 mm Hg after abdominal insufflation in both groups (P = .850 and .376). Alveolar-arterial oxygen gradient similarly increased within 30 minutes after tracheal intubation both in PCV and VCV groups, with small trend of being higher in the VCV group. The ratio of dead space to tidal volumes (VD/VT) did not have a meaningful change (P = .724). Conclusion: PCV was noninferior to VCV during laparoscopic bariatric surgery. Either mode of ventilation could be alternatively used during the anesthesia care of these patients. © 2020 American Society for Bariatric Surger