فصلنامه بیهوشی و درد
سال یکم شماره 4 (تابستان 1390)

Blood loss in spine surgery is an important issue, even though it has been understudied compared to hip and knee arthroplasty surgery. In this study we have evaluated the effect of oral clonidine as premedication on blood loss in lumbar spine fusion surgery under propofol and remifentanil anesthesia. In this prospective double-blinded randomized clinical trial, 30 patients undergoing lumbar spine posterior fusion surgery were randomly allocated into 2 groups. The study group (Clonidine group) received 200micg oral clonidine tablet 60-90 minutes before anesthesia and the control group received placebo at the same time. Induction and maintenance of anesthesia and the target mean arterial pressure for controlled hypotension with remifentanil were the same in the 2 groups. We compared the amount of blood loss, dose of remifentanil /hour administered, need for nitroglycerine to reach the target mean arterial pressure when remifentanil was not enough, duration of operation and surgeon's satisfaction of a bloodless field between the 2 groups. There was no statistically significant difference between the study groups in demographic characteristics (age (p=0.115), sex (p=0.439), weight (p=0.899)); operation time (p=0.2) and American Society of Anesthesiologists physical status score of the patients (p=0.390).Intra-operative blood loss and remifentanil dosage administered per hour in the clonidine group were significantly less than the control group (p=0.002 and p=0.001 respectively). But there was no significant difference in surgeon's satisfaction between the two groups (p=0.169). Clonidine as an oral premedication can reduce surgical blood loss in lumbar spine posterior fusion surgery, even at the same levels of mean arterial pressure with the control group. Its use can be studied in more complicated spine surgeries such as scoliosis and spinal deformity surgeries.

According to the importance of hemodynamic stability during anesthesia, usage of drugs and technics which change the hemodynamic in a minimum rate has become one of the most important purposes.Widely spread usage of propofol for sedation in cataract surgery made us to evaluate the effect of ketamine,which in itself has sympathetic effects, in usage accompaning with propofol. In a double blinded clinical trial 110 patients whom were candidate for cataract surgery were divided in two groups accidentally. After dripping topical analgesic drop and intravenous fentanyl injection 1mcg/kg: In one of the groups 0.25 mg/kg ketamine and in the other one 2cc normal saline were injected. Propofol infusion was started up to reaching to Ramsy score 3. Blood pressure, pulse rate and arterial O2 saturation were measured before and after injection of drug or placebo and also every 2 minutes for 10 minutes and the every 5 minutes up to end of surgery and transportation to recovery. Recovery time and propofol prescribed dosage were also measured. The results were analyzed with SPSS software. The average of systolic blood pressure and diastolic blood pressure was higher in 2 and 6 minutes and diastolic blood pressure was higher in minute 4 in ketamine group after injection. After injection and 2 minute later the average of pulse rate was higher in ketamine group. Also the usage of propofol in ketamine group was less and the recovery time was longer. Although the recovery time in ketamine - propofol usage is longer but it provides a better stability in patients hemodynamic and also reduces the propofol dosage.

Several reasons cause to pain in ICU patients. The pain brings some side effects in the patients so that different methods have been introduced for pain reduction. The aim of this study was comparison the effect of epidural fentanyl injection with intravenous fentanyl injection for analgesia and the effect of these two methods on ICU patient's continuousness level. This investigation was a single-blind clinical trial in ICU patients of Shahid Bahonar Hospital in Kerman. These patients suffered from abdominal and chest trauma that were mechanically ventilated. Sixty patients were assessed in two groups. Patients in Group A received intravenous fentanyl for first 24 hrs, and then get epidural fentanyl from epidural catheter. Patients in B group were injected by epidural fentanyl in first 24 hrs, and then by intravenous fentanyl in second 24 hrs. Levels of fentanyl were 1.5 mcg.kg-1 intravenous injection and 8 mcg.kg-1 for epidural injection that were regulated with injection pump. Glascow Coma Scale and Visual Analogue Pain Score were assessed in 0, 2, 6, 24, 50, 54 and 72 hours. In both groups, pain score in 2 hours was significantly lower in intravenous injection than epidural way but after 6 hours, epidural way cause to relieve pain than intravenous way (P<0.05). In all items, fentanyl intravenous injection cause to decrease patients GCS than epidural way (P<0.05). There were no significant differences between patient's pain score and GCS with their age, sex, and trauma (abdomen, chest or both of them) (P>0.05). The best way of pain control in mechanically ventilated patients with abdominal and chest trauma is intravenous injection of fentanyl in the first 2 hours and epidural injection of it in other hours. In addition, intravenous injection of fentanyl always decreases consciousness level more than epidural way.

Although its prevalence has reduced since introduction of small size spinal needles, post dural puncture headache is a still a common problem in young women. Headache could appear several hours to seven days after dural puncture, and could be a cause for delayed hospital discharge. (There are several methods for prevention and treatment of this side effect such as complete bed rest, hydration, non-opioid analgesics, caffeine, codeine, which none of them proved to be totally effective. The last option would be epidural blood patch).Methods and Materials: Sixty parturients aged 18-45 years old in American Society of Anesthesiologist (ASA) class of I or II, who had no past history of headache, analgesic consumption, substance abuse and drug addiction, candidate for elective cesarean section, were randomly assigned into two groups of case (Dexamethasone) and control (Norman saline). The anesthesia method for both groups was precisely the same. After spinal anesthesia 8 mg of intravenous Dexamethasone and 2 ml of intravenous normal saline were infused for case and control groups respectively, then at 1st, 6th,18th and 24th hours and 2nd, 3rd, 4th, 5th,6th and 7th days post operative, patients were asked about headache. There were no demographic differences between two groups. The differences of headache prevalence in all times post operative, were sot statistically meaningful between two groupsConclssion: This study showed that 8mg of intravenous Dexamethasone does not have any significant effect on headache prevalence in parturients after spinal anesthesia for elective cesarean section.

Postoperative analgesia is one of the most concerns of anesthesiologist and patients. Systemic opioids administration is the gold standard in reducing the severe pain after surgery but some side effects prevent the use of adequate doses of opioids. The aim of this study was evaluation of adding acetaminophen on fentanyl in patient-controlled iv analgesia (PCIA). In this randomized clinical trial, 120 patients candidate for lower limb orthopedic surgery (ASA I-II) were recruited in Rasoul-Akram Medical Center in a 12- month period. They randomly allocated in two groups for postoperative pain, group F (Fentanyl) ((n=60) and group AF (Acetaminophen/ Fentanyl) (n=60) by patient-controledl intravenous analgesia (PCIA) groups. The pump has a continuous infusion of 5 ml per hour, bolus dose 2 ml and the lock out time 30 minutes was left. Each ml of solution in group F containing 10 mcg of fentanyl and in the group AF containing 5 mcg fentanyl and 20 mg acetaminophen. Pain score, sedation score, satisfaction, nausea and vomiting was evaluated for 48 hours after surgery. The demographic characteristics of the two groups did not differ significantly. Pain scores befor pump in F and AF groups were 6.8±1.6 and 6.5±1.4, respectively. After 24 and 48 hours pain scores (2.4± 0.8, 1.7± 0.7) and (1.9± 0.6, 1.2± 0.5) decreased (P<0.001). Changes in pain scores were similar in both groups. Level of sedation, nausea and vomiting in the F group and satisfaction in the AF group was higher. This study showed adding iv acetaminophen to fentanyl through an PCIA is effective in controlling pain in patients undergoing lower limb orthopedic surgery. Moreover, acetaminophen and fentanyl combination and has fewer side effects such as nausea, vomiting and sedation and more satisfaction than fentanyl alone.

Distal symmetric polyneuropathy was the most common diabetic neuropathy that caused to significant disability. Sever pain، decrease and absence of sense and increase risk of ulcer and amputation were the complication of diabetes. Several therapeutic modalities used for pain control in these patients but none of them didn''t provide complete consensually of patients. The aim of this study was evaluation of the effect of low-intensity laser on limb neuropathic pain in patients with diabetes mellitus. In a Randomized Controlled Trial study with placebo، 30 patients with diabetic neuropathy، according to Electromyographic results، were included in two groups. In study group (15patients) irradiated from the Lumbosacral nerves to internal Maleous by infrared laser 980 nanometer، 200miliwaat، in 8 point. Each point applied 10 joule during 12 sessions. In control group (15patients) irradiated the same way with zero power. Effect of low-intensity laser on neuropathic lower limb pain were assessed and recorded by VAS scale at the end of every week. Nine of patients were male and 21 of them were female. Mean base pain score of patient in low-intensity laser group was 9. 53 ± 0. 63 and Mean base pain score of patient in placebo low-intensity laser group w 9. 53 ± 0. 63 (P=1). Mean pain score of patient after one week in low-intensity laser group was 7. 26 ± 1. 59 and Mean pain score of patient after one week in placebo low-intensity laser group was 8. 40 ± 1. 12 (P=0. 299). Mean pain score of patient after two week in low-intensity laser group was 5. 80 ± 1. 42 and Mean pain score of patient after two week in placebo low-intensity laser group was 8. 47 ± 0. 74. Mean pain score of patient after three weeks in low-intensity laser group was 3. 80 ± 1. 56 and Mean pain score of patient after three weeks in placebo low-intensity laser group was 8. 06 ± 0. 59. Mean pain score of patient after fore weeks in low-intensity laser group was 3. 26 ± 2. 40 and Mean pain score of patient after fore weeks in placebo low-intensity laser group was 8. 46 ± 0. 51 Mean pain score in end of two، three and four weeks in patients of low-intensity laser group were significantly lower than mean pain score in end of two، three and four weeks in patients of placebo low-intensity laser group (P<0. 001). Significantly decrease was found in pain score in low-intensity laser group patients in weeks after treatment.

Efficacy of preoperative oral administration of celecoxib to prevent postoperative pain has been proved in several studies. Also some studies were done about efficient and enough dose to control postoperative pain but there is no agreement about administration in one single dose or administration in short divided doses. In this study, we conducted to evaluate the clinical efficacy of two different doses (200 mg and 400 mg) of celecoxib, as selective cyclooxygenase-2 inhibitors, on acute pain severity after orthopedic surgeries. In this randomized clinical trial, 60 patients candidate leg fracture fixation under spinal anesthesia were enrolled. After taking informed consent, The patients were assigned randomly between three groups (group A: 400 mg at night before surgery, group B: 200 mg night before surgery and 200 mg in the morning and group C: no premedication). The severity of pain was evaluated by VAS(visual analogue scale),the time of anlgesic request by the patient and amounts of opioids administered during 24 hours after surgery was recorded and compared. There was no statistically significant difference between three groups regarding to age, sex, and duration of operation time. The mean pain severity after 6 hours (post-operation) was the same in three groups. The mean of time of analgesic request after operation was 196.5±121 minute in patients receiving 400 mg celecoxib in which it was significantly greater than the others (p=0.01). the mean of opioid consumption in patients receiving 400 mg celecoxib was less than the other groups but it didnt show any significant difference. Our study showed that administration of 400 mg celecoxib single dose was effective to postpone time of opioid request after leg fracture operation under spinal anesthesia, but in comparison with two divided doses of 200 mg celecoxib, it didnt have any significant difference on postoperative severity of pain. Also single dose (400mg) reduced the amounts of opioid consumption compared to two divided 200mg dose.

Although pregabalin shows efficacy against neuropathic pain, very limited evidence support postoperative analgesic efficacy. Our study objective to investigate analgesic efficacy of oral pregabalin in orthopedic surgery postoperative pain and opioid consumption. A randomized, double-blind, placebo-controlled was performed in. Patients received in first groupand in second group(30 patients) PCA morphine (10 mg/100ml) + oral pregabalin 300 mg daily for 48h after surgery. Pain score (VAS) and opioid consumption assessed in 48 hr after surgery. There was not significant difference between groups for demographic data. Pain score and opioid consumption in pregabaline group was significantly lower than morphine group without any significant complications. preoperative oral dose of 300 mg pregabalindailyfor 48h after surgery reduces post operative acute pain in orthopedic surgery.

Renal dysfunction in the surgical patient is usually multifactorial: the most common cause is acute tubular necrosis (ATN) as a result of hypoxic damage to renal cells. Intra-operative events such as hypoxia and hypotension undoubtedly play an important role in this regards. Besides, among the peri-operative risk factors for ATN we can mention history of ischemic heart diseases and hypertension, age more than 65 years, diabetes mellitus, ACE inhibitor therapy, other comorbid illnesses, oliguria, sepsis, mechanical ventilation, and multiorgan failure. In this special case, as we will discuss more, you would realize that our patient was an 89 years old woman with hypertension, ischemic heart disease, and diabet, with history of myocardial infarction. She had heart failure with ejection fraction of 30% and severe pulmonary hypertension who had also AF rhythm refractory to every kind of therapy. As she had to be operated due to falling down and her inter-trochanteric fracture, spinal anesthesia was chosen for her. However following the scenario which will be mentioned, she passed away unfortunately because of post -operative ATN in the ICU.