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Anesthesiology and Pain Medicine - Volume:7 Issue: 2, Apr 2017

Anesthesiology and Pain Medicine
Volume:7 Issue: 2, Apr 2017

  • تاریخ انتشار: 1396/02/19
  • تعداد عناوین: 15
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  • Longtu Chen, Sheikh J. Ilham, Bin Feng * Page 1
    Context: Visceral pain is a leading symptom for patients with irritable bowel syndrome (IBS) that affects 10% - 20 % of the world population. Conventional pharmacological treatments to manage IBS-related visceral pain is unsatisfactory. Recently, medications have emerged to treat IBS patients by targeting the gastrointestinal (GI) tract and peripheral nerves to alleviate visceral pain while avoiding adverse effects on the central nervous system (CNS). Several investigational drugs for IBS also target the periphery with minimal CNS effects.
    Evidence of Acquisition: In this paper, reputable internet databases from 1960 - 2016 were searched including Pubmed and ClinicalTrials.org, and 97 original articles analyzed. Search was performed based on the following keywords and combinations: irritable bowel syndrome, clinical trial, pain, visceral pain, narcotics, opioid, chloride channel, neuropathy, primary afferent, intestine, microbiota, gut barrier, inflammation, diarrhea, constipation, serotonin, visceral hypersensitivity, nociceptor, sensitization, hyperalgesia.
    Results
    Certain conventional pain managing drugs do not effectively improve IBS symptoms, including NSAIDs, acetaminophen, aspirin, and various narcotics. Anxiolytic and antidepressant drugs (Benzodiazepines, TCAs, SSRI and SNRI) can attenuate pain in IBS patients with relevant comorbidities. Clonidine, gabapentin and pregabalin can moderately improve IBS symptoms. Lubiprostone relieves constipation predominant IBS (IBS-C) while loperamide improves diarrhea predominant IBS (IBS-D). Alosetron, granisetron and ondansetron can generally treat pain in IBS-D patients, of which alosetron needs to be used with caution due to cardiovascular toxicity. The optimal drugs for managing pain in IBS-D and IBS-C appear to be eluxadoline and linaclotide, respectively, both of which target peripheral GI tract.
    Conclusions
    Conventional pain managing drugs are in general not suitable for treating IBS pain. Medications that target the GI tract and peripheral nerves have better therapeutic profiles by limiting adverse CNS effects.
    Keywords: Irritable Bowel Syndrome, Clinical Trial, Visceral Pain, Visceral Hypersensitivity, Hyperalgesia, Diarrhea, Constipation
  • Hamidreza Amiri, Mojtaba Mirzaei, Mona Pournaghi, Farhad Fathi * Page 2
    Background
    Pain management after abdominal surgery is a critical issue in cancer patients undergoing laparotomy. Opioid analgesics commonly used postoperatively have significant side effects and can postpone restoring normal life. Administration of analgesics before the surgery by inhibiting pain cascades may be an effective method for more efficient pain control.
    Objectives
    This study aimed to investigate the effect of the preemptive use of oral pregabalin-acetaminophen-naproxen on pain control and morphine consumptions in cancer patients undergoing laparotomy.
    Patients and
    Methods
    A total of 40 cancer patients scheduled for open abdominal surgery were randomized into the two groups. one group received combination of pregabalin 150 mg, acetaminophen 1 g and naproxen 250 mg (the PAN group) an hour before laparotomy. Following the surgery, morphine was administered on a protocolized schedule based on patients’ demand for pain control. Postoperative pain level was assessed using universal pain assessment tool (UPAT) at 0, 2, 4, 6, 12, 24 and 48 hours after the operation. The postoperative morphine dose and complications were noted. Data were analyzed using SPSS version 16.
    Results
    Patients in the PAN group had significantly lower UPAT scores at 0, 2, 4, 6, 12, 24 and 48 hours after the surgery than those in the control group (P = 0.008, 0.021, 0.008, 0.047, 0.004, 0.001, and 0.001). The mean dose of postoperative morphine consumption in the PAN group was 37% less than the control group (P = 0.001). The complications were not significantly different between the two groups.
    Conclusions
    Preemptive use of pregabalin-acetaminophen-naproxen decreases intensity of pain and morphine consumption in the cancer patients after laparotomy without significant complications.
    Keywords: Analgesia, Pain Management, Preoperative Care, Anti, Inflammatory Agents, Surgery
  • Mir Mousa Aghdashi, Mohammad Amin Valizade Hasanloei *, Rahman Abbasivash, Shahram Shokouhi, Shahram Salehi Gharehvaran Page 3
    Background
    Laryngeal mask airway (LMA) is frequently used as a replacement method for endotracheal intubation. Few studies have investigated placement of laryngeal mask airway in pediatric surgical patients. In the present study, we aimed at comparing the success rate of 2 techniques, classic versus rotational, in the correct placement of laryngeal mask airway in pediatric patients.
    Methods
    After obtaining approval from the research committee of Faculty of Medicine, and receiving clearance from the ethics board of the University, this randomized controlled clinical trial (RCT) was administered on children of 2 months to 8 years with ASA class I & II undergoing lower abdominal surgical procedures in Motahari hospital in Urmia. General anesthesia using muscle relaxant was the preferred anesthesia technique for all the patients. Demographic data were recorded. Success rate, number of trials for correct placement, cuff leak pressure, and blood stain on the cuff of the laryngeal mask airway after its removal were all recorded.
    Results
    In the present study, 116 children were evaluated and placed into 2 groups. According to the results of the t test, no significant effect of age, weight, or average number of trials in mask placement was observed between the 2 groups (P > 0.05). According to the results of the Fisher’s exact test, no significant difference was detected between the 2 groups in blood staining on the cuff (P > 0.05); no leak was recorded in any of the LMA placement methods (classic or rotational).
    Conclusions
    Both insertion techniques work well in pediatric surgical patients. Success rate and complications were comparable between the 2 groups.
    Keywords: Laryngeal Mask Airway, Airway Management, Pediatric Airway
  • Ladan Eslamian, Azade Kianipour *, Seyed Ali Reza Mortazavi Page 4
    Background And Objectives
    Several methods have been proposed to relieve orthodontic pain, each with its advantages and disadvantages. This study aimed at assessing the efficacy of 5% naproxen gel to relieve pain associated with orthodontic separator placement.
    Methods
    This double-blind randomized controlled trial was conducted on 41 patients between 14 and 20 years old complaining of pain due to placement of orthodontic elastic separators. Five-percent naproxen and placebo gels were applied randomly in a spilt mouth design to the permanent first molars area. The gels were applied every 8 hours for 3 days after placement of separators. Patients recorded their level of pain at determined time points using a 0 to 100 visual analog scale. Normal distribution was assessed by the Kolmogorov-Smirnov test. Paired samples t test was used to compare the mean pain score between the two gels. Multi-factorial repeated measures analysis of variance (ANOVA) compared the severity of pain based on gender and age.
    Results
    Out of 41 patients, 34 completed this trial (23 females and 11 males). The mean pain score significantly decreased over time in both sides and for both genders (P
    Conclusions
    Using 5% naproxen gel is an effective method for reducing orthodontic pain following elastic separator placement.
    Keywords: Pain Management, Orthodontic Treatment, Gel, Analgesia
  • Fakhrudin Faizi, Abbas Tavallaee*, Abolfazl Rahimi, Masoud Saghafinia Page 5
    Background
    Lifestyle modification has a significant role in chronic daily headache (CDH) management. Participatory action research (PAR) can play an important role in managing chronic medical conditions. However, it has been scarcely used in CDH management.
    Objectives
    This study aimed to empower patients with CDH to modify their lifestyle in order to reduce both their headache and related psychiatric co-morbidities in a multidisciplinary headache clinic at Baqiyatallah hospital, Tehran, IR Iran.
    Methods
    In the PAR plan, 37 patients (27 females) diagnosed with CDH were selected using purposeful sampling. Along with face-to-face group sessions, all available communication means such as phone calls, emails, short message system (SMS), and social media (Telegram) were used to facilitate the process. Questionnaires of health promotion lifestyle profile (HPLPІІ), visual analog scale (VAS), and depression-anxiety-stress scale (DASS21) were used to collect data. The data were analyzed using SPSS software.
    Results
    Mean age of the patients was 38. 33 (± 9. 7) years. Both “general pain” and “the worst imaginable pain” reduced (mean of reduction: 2. 56 ± 2. 7 and 2. 3 ± 2. 9, respectively, P 50% of pain reduction occurred in “the worst imaginable pain« category (-1. 45 ± 2. 02, P
    Conclusions
    The empowering PAR plan combined with new communication tools helped the CDH patients better handle their lifestyle, reduce their headache, and lower their symptoms. Further studies with better use of currently available communication tools and social media are recommended for action research to be more applicable.
    Keywords: Headache Disorder, Patient Participation, Life Style, Psychiatry, Communication
  • Pooran Hajian, Mahshid Nikooseresht *, Tayebe Lotfi Page 6
    Background
    Hypotension is one of the most common complications of spinal anesthesia in parturients undergoing cesarean section. In this regard, the patient’s position may affect the incidence of hypotension.
    Objectives
    In this clinical trial, we evaluated the effects of 1- and 2-minute sitting positions versus immediately lying down after spinal anesthesia on hypotension and vasopressor requirements.
    Methods
    A total of 72 parturients, scheduled for cesarean section under spinal anesthesia, were randomly divided into 3 groups (24 subjects per group). Groups S1 and S2 remained in a sitting position for 1 and 2 minutes after the induction of spinal anesthesia, respectively, while group T was immediately placed in a lying position. Systolic, diastolic, and mean arterial blood pressure, as well as heart rate, was recorded at 1, 2, 3, and 5 minutes after anesthesia induction, every 5 minutes during the first 30 minutes of surgery, and then every 10 minutes until the end of surgery. P-value less than 0.05 was considered statistically significant.
    Results
    The overall frequency of hypotension was 50 (69%) cases during surgery; the reported frequency was higher in group T in comparison with group S2 (P = 0.003). The frequency of hypotension before delivery (the first 5 minutes after spinal anesthesia) was 40 (55%) cases, with a higher frequency reported in group T (20, 83%), compared to groups S1 (12, 50%) and S2 (8, 33%) (P = 0.03 and P = 0.001, respectively). The ephedrine requirement in group T (11.73 ± 7.16 mg) was higher than the other two groups (8.69 ± 7.57 and 7.82±7.95 mg in groups S1 and S2, respectively); nevertheless, the difference was not statistically significant (P = 0.19). Moreover, the difference in time to achieve T6 sensory level was only significant between group T (3.25 ± 1.1 minutes) and group S2 (4.73 ± 1.73 minutes) (P = 0.03).
    Conclusions
    The present study showed that 1- or 2-minute sitting position after spinal anesthesia with 2.5 cc of hyperbaric bupivacaine in elective cesarean section results in more hemodynamic stability, compared with immediately lying down.
    Keywords: Patient Positioning, Anesthesia, Spinal, Cesarean Section, Hypotension
  • The Effect of Intravenous Magnesium Sulfate Versus Intravenous Sufentanil on the Duration of Analgesia and Postoperative Pain in Patients with Tibia Fracture
    Ali Reza Olapour, Ahmad Reza Mohtadi, Mansour Soltanzadeh, Ali Ghomeishi, Reza Akhondzadeh *, Maryam Jafari Page 7
    Background
    In the recent decades controlling postoperative pain has become a popular topic as it leads to the patients’ wellbeing and improved life quality, while it reduces the costs for both patients and medical facilities.
    Objectives
    This study aimed at comparing intravenous magnesium sulfate versus intravenous sufentanil on the duration of analgesia and postoperative pain in patients undergoing tibia fracture surgery.
    Methods
    This double blind clinical trial study was performed on 70 candidates of tibia fractures between the ages of 18 and 55 years with American society of anesthesiologists (ASA) class I and II. The patients were randomly divided to 2 groups, 1 receiving magnesium sulfate (M) and another receiving sufentanil (S). Both of the groups underwent spinal anesthesia with 10 mg bupivacaine 0.5%. One hour after ensuring the sensorimotor blockade, in the S group 0.1 µg/kg/hour and in the M group 8 mg/kg/hour was diluted in 1 liter of Ringer’s solution and infused. In this study, full weakness of the lower limb was considered as the sign of sensorimotor blockade initiation. The postoperative pain intensity was measured using the Visual Analog Scale (VAS), 0, 1, 4, 8, 16, and 24 hours after the end of anesthesia duration. In case of VAS ≥ 3, the patients received 0.3 mg/kg pethidine, intravenously. At last, the time of requesting the first narcotic drug and the total usage of pethidine were recorded.
    Results and
    Conclusions
    Sufentanil was found to be more effective than magnesium sulfate in reducing postoperative pain and the time of first narcotics request was later in patients receiving sufentanil (P
    Keywords: Tibia Fracture, Spinal Anesthesia, Postoperative Pain, Magnesium Sulfate, Sufentanil
  • Mostafa Sheykhotayefeh, Reza Safdari *, Marjan Ghazisaeedi *, Seyed Hossein Khademi, Seyedeh Sedigheh Seyed Farajolah, Elham Maserat, Mohammad Jebraeily, Vahid Torabi Page 8
    Background
    Caesarean section, also known as C-section, is a very common procedure in the world. Minimum data set (MDS) is defined as a set of data elements holding information regarding a series of target entities to provide a basis for planning, management, and performance evaluation. MDS has found a great use in health care information systems. Also, it can be considered as a basis for medical information management and has shown a great potential for contributing to the provision of high quality care and disease control measures.
    Objectives
    The principal aim of this research was to determine MDS and required capabilities for Anesthesia information management system (AIMS) in C-section in Iran.
    Methods
    Data items collected from several selected AIMS were studied to establish an initial set of data. The population of this study composed of 115 anesthesiologists was asked to review the proposed data elements and score them in order of importance by using a five-point Likert scale. The items scored as important or highly important by at least 75% of the experts were included in the final list of minimum data set.
    Results
    Overall 8 classes of data (consisted of 81 key data elements) were determined as final set. Also, the most important required capabilities were related to airway management and hypertension and hypotension management.
    Conclusions
    In the development of information system (IS) based on MDS and identification, because of the broad involvement of users, IS capabilities must focus on the users’ needs to form a successful system. Therefore, it is essential to assess MDS watchfully by considering the planned uses of data. Also, IS should have essential capabilities to meet the needs of its users.
    Keywords: Anesthesia, Cesarean Section, Information System, Information Management, Data Set
  • Junko Nakahira *, Shoko Nakano, Toshiyuki Sawai, Junichi Ishio, Naomi Ono, Toshiaki Minami Page 9
    Background
    In this study, we investigated the causes of high respiratory resistance that is observed after general anesthesia. We focused on respiratory resistance at 5 Hz (R5), which were measured preoperatively and postoperatively.
    Methods
    Our prospective observational study enrolled 68 patients who underwent transurethral resection of bladder tumors from April to October 2015. Respiratory impedance was measured the day before surgery and immediately after general anesthesia. Participants were divided into 2 groups: Group L (postoperative R5 values
    Results
    Significant parameters were height, inhalation of desflurane, endotracheal suctioning, and preoperative R5 value. Logistic regression showed that endotracheal suctioning and a higher preoperative R5 level increased postoperative respiratory resistance (> 4 cmH2O/L/sec).
    Conclusions
    The endotracheal suctioning at the end of anesthesia influenced respiratory resistance more than use of the endotracheal tube and desflurane.
    Keywords: Forced Oscillation Technique, Respiratory Impedance, Ventilator, Induced Lung Injury, Mechanical Ventilation, General Anesthesia
  • Ali Arhami Dolatabadi, Elham Memary, Hamid Kariman, Kambiz Nasiri Gigloo *, Alireza Baratloo Page 10
    Background
    This double-blind randomized clinical trial aimed at comparing the effect of intranasal desmopressin with that of intravenous ketorolac in pain management of patients with renal colic referring to the emergency department.
    Methods
    The patients were randomly divided to two groups. One group received intravenous ketorolac 30 mg and intranasal normal saline, while, the other one received intranasal desmopressin 40 μg and 1 mL of intravenous distilled water. The patients’ pain was evaluated using the visual analog scale at the time of admission, 10, 30, and 60 minutes after drug administration.
    Results
    Overall, 40 patients with mean age of 32.53 ± 6.91 participated in this study. Gender ratio (P = 0.288), mean age (P = 0.165), and mean pain score on arrival (P = 0.694) had no significant difference. The mean pain scores, 10, 30, and 60 minutes after drug administration in the ketorolac group was significantly lower than the desmopressin group, and decreased more rapidly (P
    Conclusions
    It is likely for desmopressin to be less efficacious than ketorolac, and desmopressin leads to a significant alleviation of pain in patients with renal colic.
    Keywords: Desmopressin, Ketorolac, Pain Management, Emergency Department
  • Hassan Mohamed Ali *, Ashraf Hamed Shehata Page 11
    Introduction
    TAB block has been used as an analgesic adjuvant in many abdominal surgeries with fair reliability, but it has never been used as an anesthetic technique.
    Case Presentation
    In this case report, a 19- year-old male underwent an open appendectomy using ultrasound-guided TAP block as a single anesthetic technique.
    Conclusions
    It was concluded that under certain circumstances TAP block can be used as an anesthetic modality
    Keywords: Anesthetics, Local, Appendectomy
  • Sujata Anipindi *, Nadir Ibrahim* Page 12
    Introduction
    We present a case of paraplegia due to cord compression from epidural hematoma following an uneventful epidural catheter insertion in a patient with ankylosing spondylitis.
    Case Presentation
    A 65-year-old gentleman was scheduled for a major laparotomy for abdominal wall reconstruction. He has a past medical history of mild asthma, ankylosing spondylitis, duodenal ulcer and a superior mesenteric artery thrombosis in the past which led to bowel ischemia and intestinal failure. His drug allergies included Oxycodone. The anaesthetic plan was to do an awake epidural with catheter insertion followed by a general anaesthetic. The insertion of the epidural and the catheter was uneventful with the space identified in first attempt and no bloody tap. Intra-operative analgesia was maintained by a continuous epidural infusion of low dose local anaesthetic and opioid. The total operative time was eight hours and the patient was extubated at the end of the surgery. Following extubation, the motor block was checked in recovery using the modified Bromage scale. A dense block was noted and the epidural infusion was stopped. An MR scan was performed immediately, which showed an epidural hematoma in T5 - T11 segments. An urgent decompressive laminectomy was performed to evacuate the haematoma. However, neurological recovery was minimal with persistent paraplegia.
    Conclusions
    The increased incidence of epidural haematoma in patients with ankylosing spondylitis is well documented . Earlier detection and decompression can help in preserving neurological function. We recommend being more cautious when the decision for epidural analgesia is made in patients with higher grades of ankylosing spondylitis. If an epidural is considered necessary, use of x-ray guidance and some form of intra-operative neurological monitoring should be considered, particularly in prolonged surgeries which last over several hours.
    Keywords: Complications, Epidural, Analgesia, Paraplegia, Spondylitis, Ankylosing, Spinal Epidural Hematoma
  • Mehdi Fathi, Susan Aziz Mohammadi, Mehdi Moslemifar, Kurosh Kamali, Marjan Joudi *, Azam Sabri Benhangi, Mojtaba Mohaddes, Mona Joudi, Mozhgan Mohajeri Page 13
    There are many acceptable approaches ranging from light to moderate intravenous sedation or analgesic drugs that are used to provide pain control in dilatation and curettage. We report the use of hypnosis as a nonpharmacologic approach to control pain in this manner.
    Keywords: Hypnosis, Hypnoanalgesia, Metrorrhagia, Uterine Bleeding
  • Omar Viswanath, Rekha Suthar, Murlikrishna Kannan*, Michael Baskin Page 14
    Introduction
    Cervical radiculopathy is a common condition affecting many people each year. The efficacy of cervical epidural steroid injection for patients that have not responded to conservative treatment has been demonstrated. Even with confirmatory radiocontrast dispersion indicating correct presence in the epidural space, there still may be rostral spread of steroid and local anesthetic resulting in an unusual presentation of symptoms and potentially life threatening complications.
    Case Presentation
    We present the case of a 52-year-old male presenting for a right sided C6-C7 epidural steroid injection. The epidural space was identified and a Tuohy needle was advanced using loss of resistance technique. Isovue contrast was used for needle localization and after confirmation of the presence of the contrast in the epidural space, dexamethasone and lidocaine were injected to the area without any complications. Five minutes after arrival to the PACU, the patient developed a constellation of symptoms including inability to swallow, vertigo, and horizontal nystagmus which required reassurance and vigilant monitoring.
    Conclusions
    Interventional pain physicians must be cognizant that even with confirmatory epidural radiocontrast dispersion, there still may be inadvertent uptake of steroid and local anesthetic rostrally resulting in an unusual presentation of symptoms and potentially life threatening complications. Potential reasons for the rostral spread include inadvertent subdural or intrathecal injection.
    Keywords: Epidural Injection, Post Procedure Complication, Subdural Injection, Nystagmus, Local Anesthetic Toxicity