Anesthesiology and Pain Medicine

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In Collaboration with Society of Regional Anesthesia and Pain Medicine (ISRAPM)

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The Anesthesiology and Pain Medicine journal, official publication of ISRAPM since 2011, offers comprehensive insights into pain management research, education, and clinical practice. It features a broad spectrum of content, including research, reviews, and debates relevant to anesthesiologists, neurosurgeons, and pain specialists.

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Comparison of the Preemptive/Preventive Effect of Dexmedetomidine and Ketorolac on Post-operative Pain of Appendectomy Patients: A Randomized Clinical Trial
(Brieflands, 2024-12-31) Sepideh Pakniyat; Ghasem Mousavi; Hashem Jarineshin; Fereydoon Fekrat; Narjes Sabet; Alireza Abdullahzadeh-Baghaei
Objectives: The primary objective was to test the hypothesis that the preemptive/preventive effect of Dexmedetomidine would attenuate the post-operative pain more effectively compared to ketorolac and control groups. Methods: This study was conducted in Shahid Mohamadi Hospital. Sixty patients undergoing appendectomy operations were randomized in 3 groups. Group A received intravenous Dexmedetomidine bolus (1 μg/kg) and infusion (0.5 μg/kg/h). Group B received slow intravenous bolus ketorolac 30 mg. Group C was the control group. Post-operatively fentanyl (5µg/mL) as patient control analgesia (PCA) was provided only on demand. The primary outcome was the Visual Analogue Scale (VAS) pain scores recorded at 1, 3, 6, 12 and 24 hours postoperatively. The secondary outcome was the 24-hour cumulative fentanyl PCA dose. Tertiary outcomes; changes in blood pressure, heart rate, body temperature, SpO2 perioperatively. Quaternary outcomes were PONV, shivering. Results: In the Dexmedetomidine group the mean ± SD pain VAS scores 1.15 ± 1.98 and 0.95 ± 1.76 were significantly lower at 12 and 24 hours after operation (P = 0.004 and P = 0.003) compared to the other two (ketorolac and control) groups. The cumulative volume dose of fentanyl PCA 21.35 ± 11.77 mL was less in the Dexmedetomidine group compared to ketorolac (28.35 ± 9.82 mL, P = 0.629) and control (40.35 ± 12.90 mL, P = 0.003) groups. Conclusions: Preemptive/preventive effects of Dexmedetomidine were greatest after operation compared to the ketorolac and control groups in the terms of pain scores and amount of analgesia needed postoperatively.
Opioid-Free Anesthesia for Upper Limb Surgery in Obese Patients as a Day Case Surgery: A Prospective Observational Study
(Brieflands, 2024-12-31) Rana Ahmed Abdelghaffar; Mohamed Ahmed Hamed; Mohammed Magdy Basiony; Mohammad Fouad Algyar; Omar Sayed Fargaly; Mohamed Ahmed Shawky
Background: Opioid-free anesthesia (OFA) is a relatively new approach, and many studies are still needed to assess its effectiveness and compare it to opioid-based anesthesia (OBA). Objectives: This study investigated the use of OFA in obese patients undergoing upper limb surgery and compares its outcomes with those of OBA. Results: The OFA group had significantly lower extubation time, mean arterial pressure (MAP), and heart rate (HR) compared to the OBA group. Additionally, VAS scores were significantly lower at the 30-minute and 2-hour marks after extubation (P < 0.001 and P < 0.001, respectively) in patients receiving OFA. The OFA group also experienced fewer adverse effects, required fewer rescue doses of tramadol, and had shorter hospital stays. Conclusions: Opioid-free anesthesia may result in better and safer outcomes for obese patients undergoing upper limb surgeries, with fewer postoperative complications and shorter hospital stays. However, further research is needed to fully understand the potential benefits of OFA compared to OBA.
Comparison of Pregabalin and Midazolam as Premedication in Children Undergoing General Anesthesia for Dental Treatment
(Brieflands, 2024-12-31) Maryam Hajiahmadi; Nasser Kaviani; Elahe Asnaashari Esfahani; Sanaz Rajaee
Background: Pediatric dentists employ both pharmacological and non-pharmacological behavior control methods. Despite the use of behavioral control techniques, some young children cannot undergo treatment in the office, making sedation or general anesthesia necessary. Premedication drugs can be used before general anesthesia to reduce anxiety, control pain, induce amnesia, prevent nausea, and avert potential complications. The search for the ideal premedication for children is ongoing. Objectives: This study aims to compare the effects of pregabalin and midazolam (MID) in children undergoing dental treatment under general anesthesia. Methods: This prospective, triple-blind study included 64 children aged 2 - 6 years who required dental treatment under general anesthesia. Participants who met the inclusion criteria were enrolled. One group of children received pregabalin syrup, while the other group received MID syrup. The comfort of the child during separation from the parents, ease of venous access, and degree of sedation upon entering the operating room were evaluated. Blood pressure, heart rate, and blood oxygen levels were measured at baseline and every 30 minutes thereafter. Additionally, the duration of the patient's stay in recovery until discharge was recorded and compared between the two groups. Statistical analyses were performed using chi-square, Mann-Whitney U, Fisher's exact test, and SPSS version 14 software. Results: No statistically significant differences were found between premedication with MID and pregabalin in terms of anxiety during venous access, parental separation anxiety, restlessness in recovery, duration of recovery stay, or changes in heart rate, blood pressure, and blood oxygen levels between the two groups. However, a statistically significant difference was observed between the two groups regarding the degree of sedation before entering the operating room. Conclusions: Both pregabalin and MID were effective for premedication in terms of sedation and anxiety reduction, with no significant difference between the two drugs in these outcomes.
Postoperative Analgesia and Length of Hospital Stay After Surgery for Malignant Pleural Mesothelioma: A Retrospective Observational Study
(Brieflands, 2024-12-31) Mayuu Kobata; Kenta Takeda; Mana Taguchi; Hiroai Okutani; Takeshi Ide; Akane Kido; Kouichi Fujimoto; Masaki Hashimoto; Ryusuke Ueki; Munetaka Hirose
Background: Pleurectomy/decortication (P/D), a surgical procedure for malignant pleural mesothelioma (MPM), is a highly invasive surgery requiring prolonged hospitalization. Previous studies have reported that postoperative analgesia using regional anesthesia contributes to shorter hospital stays after surgery under general anesthesia by reducing acute postoperative pain. However, the association between postoperative analgesia and the length of hospital stay (LOHS) following P/D has not been evaluated. Objectives: To evaluate the association between postoperative analgesia and postoperative LOHS after P/D. Methods: This single-institution observational study enrolled consecutive adult patients undergoing P/D under general anesthesia, who postoperatively received either intertransverse process block (ITPB) or continuous intravenous (IV) fentanyl infusion as postoperative analgesia between March 2022 and February 2023. Results: Among all enrolled patients with ASA physical status II or III (n = 60), postoperative analgesia was administered using either continuous ITPB (n = 19) or continuous IV fentanyl infusion (n = 41). Multivariable logistic regression analysis revealed that postoperative analgesia with continuous ITPB (P = 0.007), a lower incidence of major complications after surgery (P = 0.034), and female sex (P = 0.033) were significantly associated with a shorter postoperative LOHS. In subgroup analysis, patients who received continuous ITPB had significantly lower postoperative LOHS, lower postoperative serum C-reactive protein levels on postoperative day (POD) 3, and reduced acute postoperative pain on POD3 compared to those who received continuous IV fentanyl infusion. Conclusions: Postoperative analgesia using continuous ITPB appears to be associated with a reduction in LOHS following P/D for MPM under general anesthesia.
Analyzing Patterns in Anesthesiology Residents' Exam Performance Using Data Mining Techniques
(Brieflands, 2024-12-31) Maedeh Karimian; Shahabedin Rahmatizadeh; Zeinab Kohzadi; Zahra Kohzadi; Firoozeh Madadi; Ali Dabbagh; DACCPM, Department of Anesthesiology, Critical Care and Pain Medicine
Background: Residency is a critical period in the development of medical professionals. It provides hands-on training and exposure to various medical specialties, enabling residents to improve their skills and achieve expertise in their chosen field. Objectives: This study aimed to extract frequent patterns in annual and board examination performance among anesthesiology residents by analyzing results from the department's weekly exams. Methods: This cross-sectional study was conducted in the Department of Anesthesiology, Critical Care, and Pain Medicine (DACCPM) from September 2022 to June 2023. Weekly intra-group exams were administered at the university's electronic exam center for residents in their first to fourth years (CA-1 to CA-4), with a total of 61 participants. Learner grades were categorized as excellent (A), good (B), average (C), poor (D), and inferior (E). The Apriori algorithm was employed to extract frequently repeated patterns in these exams and compare them with results from the final national examination. Results: A total of 24 exams were conducted, with all 61 residents participating. The most frequent patterns, identified with a minimum support of 0.41, revealed that residents generally achieved average scores in exam 7 and very poor scores in exams 1 and 5. The study found a statistically significant relationship between residents’ scores in in-training examinations (ITEs) and their national examination performance. Conclusions: Analyzing residents’ exam performance using frequent pattern recognition can help identify their strengths and weaknesses. Faculty members can utilize these insights to better plan curricula and enhance the quality of education.
Comparison of the Effect of High-Intensity Laser Therapy and Quadriceps Muscle Strengthening Exercises Using Biofeedback on Pain, Stiffness and Function of Patients with Knee Osteoarthritis: A Randomized Clinical Trial
(Brieflands, 2024-12-31) Maryam Sadat Rahimi; Amir Masoud Jafari-Nozad; Fatemeh Jazebi
Objectives: This study aims to compare the effects of high-intensity laser therapy (HILT) and quadriceps muscle strengthening exercises using biofeedback on pain and function in patients with knee osteoarthritis (KOA). Methods: This randomized, two-group clinical trial included patients with KOA (grades II - III of the Lawrence Kellgren classification) who met the inclusion criteria. Written informed consent was obtained from participants before they were randomly allocated into one of two groups: HILT + therapeutic exercise (group A) or quadriceps muscle strengthening exercises using biofeedback + therapeutic exercise (group B). Both groups followed the same therapeutic exercise regimen during the study. Results: The study included 40 participants with KOA, divided evenly between the two groups (20 in each). The average age of the participants was 59.34 ± 6.92 years. High-intensity laser therapy group (group A): Visual analogue scale pain scores decreased significantly immediately after and one month post-intervention compared to baseline (P < 0.01). However, the VAS score one month after the intervention showed no significant difference compared to the immediate post-intervention score (P = 0.59). Biofeedback group (group B): VAS pain scores also decreased significantly both immediately after and one month post-intervention compared to baseline (P < 0.05). The difference in VAS pain reduction between the two groups was significant, with the HILT group showing greater improvement immediately after the intervention and one month later (P = 0.007). Conclusions: The study findings suggest that both quadriceps muscle strengthening exercises using biofeedback and HILT effectively reduce pain in KOA patients. However, HILT demonstrated superior efficacy compared to biofeedback exercises. These results support the use of HILT as a noninvasive therapeutic modality for KOA, particularly for patients with a higher risk of surgery due to preexisting comorbidities.
Transient Neuronal Injury Followed by Intravascular Injection During an Ultrasound Guided Stellate Ganglion Block
(Brieflands, 2013-01-01) Hariharan Shankar; Swetha Simhan
Ultrasound guidance for pain interventions is becoming increasing recognized as a useful imaging tool. One of the common interventions where it is gaining wider acceptance is during the performance of a stellate ganglion block. The following is a unique report where intravascular and neuronal injury occurred during the performance of an ultrasound guided stellate ganglion block followed by dysphagia. 41 year old male, with a diagnosis of complex regional pain syndrome, was referred to our clinic for further management. He underwent a diagnostic ultrasound guided stellate ganglion block after having tried conservative therapies. The stellate ganglion block provided him with complete pain relief for over five weeks. During a subsequent therapeutic stellate ganglion block, performed by an experienced pain medicine fellow with more than 50 ultrasound guided proceduresclinician, the patient developed a transient injury to the brachial plexus upon needle entry. Subsequent redirection and injection of an ml of injectate resulted in an intravascular injection producing tinnitus. After the tinnitus decreased, he underwent another stellate block using an out of plane approach without any further complications. Two days later, he reported chest and throat discomfort which resolved over the next few days possibly due to a retropharyngeal hematoma. He declined further interventions and was subsequently managed with 3 tablets of oxycodone a day. This report highlights the importance of vigilance and meticulous planning during the performance of ultrasound guided pain interventions.
Management of Critically Ill Patients with COVID-19: What We Learned and What We Do
(Brieflands, 2020-06-10) Ata Mahmoodpoor; Kamran Shadvar; Ali Akbar Ghamari; Mojtaba Mohammadzadeh Lameh; Roghayeh Asghari Ardebili; Masood Hamidi; Hassan Soleimanpour
There are many unknown questions and puzzle pieces that should describe the clinical course of COVID-19 and its complications, especially ARDS. We provide the initial immediate surge response to allow every patient in need of an ICU bed to receive one. Till our knowledge is improved, the most important intervention in the treatment of critically ill patients with COVID-19 seems to be the level of standard care and appropriate and early diagnosis and treatment. It seems that each center should have its protocol on the management of critically ill COVID-19 patients regarding prevention, diagnosis, and treatment. This treatment should now be performed regardless of the reason which lies behind the pathophysiology of this disease, which is yet unknown. In this report, we share our experience in the management of critically ill COVID-19 patients during the 2 months in our intensive care unit.
Comparison of the Effect of Two Different Doses of Labetalol to Induce Controlled Hypotension on Hemodynamic Changes During Spinal Fusion Surgery
(Brieflands, 2021-10-31) Zahra Rahimi; Mehrdad Masoudifar; Behzad Nazemroaya; Haidar Almadi
Background: Spinal fusion surgery is often associated with heavy bleeding. Labetalol is one of the most effective drugs used to control bleeding in surgery. Objectives: Here, we measured the effect of two therapeutic doses of labetalol on the amount of bleeding. Methods: This is a randomized clinical trial that was performed in 2020-2021 in Al-Zahra hospital in Isfahan, Iran, on patients that were candidates for posterior spinal fusion surgery under general anesthesia. A total number of 64 patients were entered and randomized into two groups, one receiving labetalol at the dose of 2 mg/min and another group at 4 mg/min during surgery. The amount of bleeding in patients, heart rate, blood pressure, blood oxygen saturation, hypotension or bradycardia, and the mean length of stay in the recovery room were measured and compared between the groups. Results: Extubation time (14 ± 4) and recovery time (76 ± 17) were significantly lower in patients that received labetalol (2 mg/min) compared to another group (21 ± 7 for intubation time and 116 ± 32 for recovery time (P < 0.001 for both items). Patients that received labetalol (4 mg/min) had significantly lower amounts of hemorrhage compared to other group (P = 0.001), and the surgeon's satisfaction was significantly higher in the second group (P = 0.001). The frequency of hypotension and bradycardia during the surgery were significantly higher among patients that received labetalol at the dose of 4 mg/min (P = 0.002 and P = 0.001, respectively). The patients in the group labetalol at 4 mg/min had also significantly lower systolic and diastolic blood pressure and lower mean arterial pressure (MAP) compared to the other group (P < 0.05). Conclusions: Administration of labetalol at the dose of 4 mg/min had significantly desirable effects on hemodynamics that resulted in reduced bleeding volume and blood pressures compared to labetalol at the dose of 2 mg/min.
Beyond Beauty: Onobotulinumtoxin A (BOTOX®) and the Management of Migraine Headaches
(Brieflands, 2012-07-31) Devra Becker; Bardia Amirlak
Based on the conducted anatomic studies at our institutions as well as clinical experience with migraine surgery, we have refined our onobotulinumtoxin A (BOTOX®) injection techniques. Pain management physicians are in unique position to be able to not only treat migraine patient, but also to be able to collaborate with neurologists and peripheral nerve surgeons in identifying the migraine trigger sites prior to surgical deactivation. The constellation of migraine symptoms that aid in identifying the migraine trigger sites, the potential pathophysiology of each trigger site, the effective methods of botulinumtoxin and nerve block injection for diagnostic and treatment purposes, as well as the pitfalls and potential complications, will be addressed and discussed in this paper.
Caudal Additives Do Not Improve the Analgesia Afforded by Levobupivacaine After Hypospadias Repair
(Brieflands, 2012-01-01) Kay Davies; Graham Wilson; Thomas Engelhardt
Background: Caudal analgesia is commonly employed to provide excellent intra- and postoperative analgesia for primary hypospadias repair in children. Several additives to local anesthetics are commonly employed to increase the block duration, although these have uncertain benefits. Objectives: This study investigated whether, in caudal analgesia with levobupivacaine 0.25%, the addition of S (+)-ketamine, clonidine, or both agents combined, would prolong postoperative analgesia in patients undergoing primary hypospadias repair. Patients and Methods: We conducted a retrospective chart analysis for all patients who underwent hypospadias repair with caudal analgesia over a consecutive 3-period at this institution. The study examined four patient groups, classified according to the analgesia used:\r\n1) No additive, levobupivacaine alone\r\n2) Levobupivacaine and S (+)-ketamine\r\n3) Levobupivacaine and clonidine\r\n4) Levobupivacaine, S (+)-ketamine, and clonidine\r\nPrimary outcome measures were as follows: time to the first postoperative request for analgesia, total first 24-hour postoperative analgesia, and time to hospital discharge.\r\n Results: The 87 patients included had a mean ± SD age of 21.4 ± 13.5 months and weight of 11.9 ± 2.4 kg. The median doses of levobupivacaine, S (+)-ketamine, and clonidine were 0.7 mg/kg (range, 0.4–1.3), 0.5 mg/kg (0.2–1.1), and 1.8 μg/kg (0.8–2.3), respectively. The addition of S(+)-ketamine, clonidine, or both did not increase the time to first oral analgesia request. Neither did it reduce the total first 24-hour postoperative analgesia requirements or alter hospital discharge time. However, the additive drugs in combination did increase postoperative sedation. Conclusions: The addition of S (+)-ketamine or clonidine to levobupivacaine 0.25% in caudal analgesia for hypospadias repair appears to be of no benefit. However, use of the additives in combination increased postoperative sedation.
Evaluation of Analgesia Using Perineural Dexamethasone Compound in Interscalene Brachial Plexus Block After Shoulder Surgery
(Brieflands, 2024-02-29) Mahshid Ghasemi; Arman Janparvar; Faranak Behnaz; Farinaz Taheri
Background: The objective of this study was to examine analgesia when using perineural dexamethasone compound in an interscalene brachial plexus block following shoulder surgery. Methods: This study was designed as a randomized, double-blind clinical trial. Patients meeting the specified criteria were randomly divided into two groups: The experimental group and the control group, each comprising 30 individuals. Age and gender were matched between the groups. The control group received lidocaine along with 2 cc of 0.5% bupivacaine (20 milligrams) and 2 cc of normal saline; however, the experimental group received lidocaine, along with 2 cc of 0.5% bupivacaine and 2 cc of dexamethasone. Pain levels were assessed using the Visual Analog Scale (VAS), and covariance analysis was applied for data analysis. Results: The results demonstrated that pain intensity was notably lower in the experimental (dexamethasone) group than in the control group at both the 12-hour group (P < 0.001) and 24-hour (P < 0.001) postoperative marks. Dexamethasone significantly reduced pain among the patients. Conclusions: In conclusion, administering dexamethasone to potential candidates for shoulder surgery could lead to prolonged analgesia for up to 24 hours after the surgery. Consequently, this medication can serve as an efficacious analgesic option for pain management in these patients.
Retraction Note: Effect of Perioperative Intravenous Lignocaine Infusion on Haemodynamic Responses and postoperative Analgesia in Laparoscopic Cholecystectomy Surgeries
(Brieflands, 2021-10-31) Krishna Murthy TK; Vinay Kumar PV
This article does not have an abstract.
Retracted Article: The Effect of Dexmedetomidine and Esmolol on Early Postoperative Cognitive Dysfunction After Middle Ear Surgery Under Hypotensive Technique: A Comparative, Randomized, Double-blind Study
(Brieflands, 2021-02-28) Mahmoud Hussein Bahr; Doaa Abu Elkassim Rashwan; Samaa A Kasem
Objectives: Postoperative cognitive dysfunction (POCD) is multifactorial, which may be caused by anesthetic and surgical causes or cerebral injury. This study aimed to evaluate the effect of dexmedetomidine as a neuroprotective drug compared to esmolol on the prevalence of POCD in adult patients undergoing middle ear surgeries under hypotensive anesthesia. Methods: This study included male and female adult patients, according to American Society of Anesthesiology physical status (ASA) I, the patients who underwent middle ear surgeries under hypotensive anesthesia were randomly assigned to two groups that received esmolol and dexmedetomidine. The demographic data, heart rate, mean arterial blood pressure, duration of the surgery, evaluation of the surgical field, and the Mini-Mental State Examination (MMSE) (preoperatively and at 1, 6 and 24 hours postoperatively) were recorded. Results: There was a significant difference between the numbers of patients who had POCD in MMSE1: 12 cases in the esmolol group (41.37%) compared to three cases in the dexmedetomidine group (10.34%) (P = 0.016), in MMSE6: 10 cases in the esmolol group (34.48%) compared with two cases in the dexmedetomidine group (6.89%) (P = 0.023) and in MMSE24: seven cases in the esmolol group (24.13%) compared with one case in the dexmedetomidine group (3.44%) (P = 0.022), while the median and range of MMSE score were comparable between the two groups (P > 0.05). Conclusions: This study suggests that intraoperative use of dexmedetomidine as an adjuvant to hypotensive anesthesia reduces the incidence of POCD compared to esmolol.
Importance of Choice of Drugs and Timing of Their Administration
(Brieflands, 2011-12-31) Kyung Y. Yoo; Jong Un Lee
This article does not have abstract.
Comparing the Prevalence of Chronic Pain After Sternotomy in Patients Undergoing Coronary Artery Bypass Grafting Using The Internal Mammary Artery and Other Open Heart Surgeries
(Brieflands, 2014-08-01) Hamid Kamalipour; Ali Vafaei; Asef Parviz Kazemi; Saeed Khademi
Background: The prevalence of chronic postoperative pain after cardiac surgery has been reported from 17% to 56%. Objectives: We aimed to compare the prevalence of postoperative pain between patients who had undergone CABG using the internal mammary artery (IMA) and those who had undergone other cardiac surgeries including CABG using the saphenous vein or cardiac valvular surgeries. Patients and Methods: In this cohort study, medical records of 188 patients were evaluated and divided into two equal groups (94 in each group); patients who had undergone CABG using the IMA (IMA group) and those who had undergone other cardiac surgeries using the saphenous vein or other cardiac valvular surgeries (non-IMA group). The patients' data were recorded in a self-structured questionnaire and then phone interviews were performed 3 months after the operations regarding the rate of postoperative pain. The severity of chronic pain was rated based on the numerical rating pain scale. Results: The two groups differed significantly regarding the prevalence of pain (P = 0.023). In the IMA group, 83 (88.3%) patients experienced pain lasting for more than three months compared to 71 (75.5%) patients in non-IMA group. The two groups differed significantly with respect to the severity of chronic pain after cardiac surgery via sternotomy (P = 0.001). The groups did not differ significantly regarding the effects of chronic pain on their sleep, referral to a physician, and drug consumption to alleviate their pain. The IMA group experienced more complications at work and during their occupational activity. Conclusions: The rate and severity of chronic pain after cardiac surgery via sternotomy was higher in patients undergoing CABG with separation of IMA for revascularization.
Postoperative Sore Throat After Laryngoscopy With Macintosh or Glide Scope Video Laryngoscope Blade in Normal Airway Patients
(Brieflands, 2014-02-01) Atabak Najafi; Farsad Imani; Jalil Makarem; Mohammad Reza Khajavi; Farhad Etezadi; Shirin Habibi; Reza Shariat Moharari
Background: The Glide Scope videolaryngoscope provides a suitable view for intubation, with less force required. Objectives: The present study was conducted, to compare postoperative sore throat and hoarseness after laryngoscopy and intubation, by Macintosh blade or Glide Scope video laryngoscope in normal airway patients. Patients and Methods: Three hundred patients were randomly allocated into two groups of 150: Macintosh blade laryngoscope or Glide Scope video laryngoscope. The patients were evaluated for 48 hours for sore throat and hoarseness by an interview. Results: The incidence and severity of sore throat in the Glide Scope group, at 6, 24 and 48 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. In addition, the incidence of hoarseness in the Glide Scope group, at 6 and 24 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. The incidence and severity of sore throat in men, at 6 and 24 hours after the operation, were significantly lower than in the women. Conclusions: The incidence and severity of sore throat and hoarseness after tracheal intubation by Glide Scope were lower than in the Macintosh laryngoscope. The incidence and severity of sore throat were increased by intubation and longer operation times.
Improved Pain Control with Combination Spinal Cord Stimulator Therapy Utilizing Sub-perception and Traditional Paresthesia Based Waveforms: A Pilot Study
(Brieflands, 2021-02-22) Amnon A. Berger; Ivan Urits; Jamal Hasoon; Jatinder Gill; Musa Aner; Cyrus A. Yazdi; Omar Viswanath; Elyse M. Cornett; Alan David Kaye; Farnad Imani; Farsad Imani; Giustino Varrassi; Thomas T. Simopoulos
Background: Chronic back and neck pain affects 20% of Americans. Spinal cord stimulation (SCS) is an effective therapy for otherwise refractory chronic pain. Traditional SCS relies on low-frequency stimulus in the 40 - 60 Hz range causing robust paresthesia in regions overlapping with painful dermatomes. Objectives: This study aims to determine the effect of superimposing sub-perception stimulation in patients who previously had good long-term relief with paresthesia. Methods: This is a prospective observational trial examining patients who had previously been implanted with paresthesia based SCS for failed back surgery syndrome (FBSS) or complex regional pain syndrome (CRPS). These patients presented for implantable pulse generator (IPG) replacement based on battery depletion with an IPG capable of combined sub-perception and paresthesia based SCS therapy. Patients were assessed immediately following the exchange and four weeks later using a telephone survey. Their pain was assessed on each follow up using a Numerical Rating scale (NRS); the primary outcome was the change in NRS after four weeks from the exchange day. Secondary outcomes included paresthesia changes, which included the subjective quality of sensation generated, the overall subjective coverage of the painful region, subjective variation of coverage with positional changes, and global perception of the percentage improvement in pain. Results: Based on our clinic registry, 30 patients were eligible for IPG exchange, 16 were consented for follow up and underwent an exchange, and 15 were available for follow up four weeks following. The average NRS decreased from 7.47 with traditional SCS to 4.5 with combination therapy. 80% of patients reported an improvement in the quality of paresthesia over traditional SCS therapy, and in most patients, this translated to significantly improved pain control. Conclusions: Our findings suggest improved pain relief in patients who had previously had good results with paresthesia based therapy and subsequently underwent IPG exchange to a device capable of delivering combined sub-perception stimulation. The mechanism of action is unclear though there may be an additive and/or synergistic effect of the two waveforms delivered. Larger studies with long-term follow-up are needed to elucidate the durability of pain relief and the precise mechanism by which combined subperception and paresthesia based SCS may improve overall patient outcomes.
“Robo-Tripping”: Dextromethorphan Abuse and its Anesthetic Implications
(Brieflands, 2014-12-31) Kelly A Linn; Micah T Long; Paul Pagel
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.
Usefulness of Ultrasound View of Larynx in Pre-Anesthetic Airway Assessment: A Comparison With Cormack-Lehane Classification During Direct Laryngoscopy
(Brieflands, 2016-12-01) Sussan Soltani Mohammadi; Alireza Saliminia; Nasim Nejatifard; Roxana Azma
Background: One of the main challenges in anesthesiology is difficult intubation. There are many anatomical parameters for evaluating the feasibility of tracheal intubation; one that can reliably predict a difficult intubation is the Cormack-Lehane classification obtained during direct laryngoscopy. This is an invasive procedure that cannot be performed in an awake patient or for pre-anesthetic airway assessments in patients with no prior history of tracheal intubation. Recently, ultrasound has been successfully used for several airway-related applications. Objectives: The aim of this study was to compare and correlate the ultrasound view of the larynx with the Mallampati classification before anesthesia and the Cormack-Lehane classification during direct laryngoscopy under general anesthesia. Methods: This cross-sectional descriptive-analytic study included 53 ASA class I - III patients aged 18 - 70 years who were scheduled for tracheal intubation under general anesthesia. Before anesthesia, an oblique transverse ultrasound view of the airway was obtained; in addition, the total time taken to achieve the final plane, the depth of the pre-epiglottic space, and the distance from the epiglottis to the mid-point between the vocal cords were all recorded. The ultrasound measurements were then compared with the Mallampati class on the preoperative evaluation and with the Cormack-Lehane grade during direct laryngoscopy under general anesthesia. Results: It was observed that correlations between the pre-epiglottic space (PE) and Cormack-Lehane grades I, II, and III were weak. Correlations between the distance from the epiglottis to the vocal cords (E-VC) and Cormack-Lehane grades I, II, and III were also weak. The PE/E-VC ratio for correlations between the sonographic view and laryngoscopy had 87.5% sensitivity and 30% specificity. There was no correlation between Mallampati class and the PE/E-VC ratio (P = 0.566). Conclusions: Our study revealed weak correlation between PE/E-VC and Cormack-Lehane grade, with 87% sensitivity and 30% specificity. Therefore, we concluded that sonographic measurement criteria are not accurate in airway evaluations before anesthesia.

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