Anesthesiology and Pain Medicine
Volume:12 Issue: 1, Feb 2022

Spinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. The critical part of this technique is safe access to the epidural space for lead placement. There have been innovations in radiological views, improving access to the epidural space.

This study analyzes the adoption of these technical advantages in daily practice

We conducted a survey of members in the Spine Intervention Society and American Society of Regional Anesthesia in regard to the practice patterns in SCS therapy. Here we present our findings regarding the use of contralateral oblique (CLO) and lateral views as well direct upper thoracic or cervicothoracic access for SCS lead insertion

A total of 195 unique responses were received between March 20, 2020 and June 26, 2020. Forty-five percent of respondents “always used” the lateral view technique while 15% “always used” CLO view for SCS lead insertion. Overall, sixty-five percent of respondents used the CLO view with varying frequency. Cervical and upper thoracic approach for cervical SCS lead placement is always or often used by 66.8% of the respondents.

A depth view (CLO or lateral) is always used by only 45 - 60% of the respondents and CLO view has been rapidly adopted in clinical practice for SCS lead insertion. Direct cervicothoracic and upper thoracic is the preferred approach for cervical lead placement by the majority.

The treatment of pain, both acute and chronic, has been a focus of medicine for generations. Physicians have tried to develop novel ways to effectively manage pain in surgical and post-surgical settings. One intervention demonstrating efficacy is nerve blocks. Single-injection peripheral nerve blocks (PNBs) are usually preferred over continuous PNBs, since they are not associated with longer lengths of stay. The challenge of single injection PNBs is their length of duration, which at present is a major limitation. Novel preparations of local anesthetics have also been studied, and these new preparations could allow for extended duration of action of anesthetics. An emerging preparation of bupivacaine, exparel, uses a multivesicular liposomal delivery system which releases medication in a steady, controlled manner. Another extended-release local anesthetic, HTX-011, consists of a combination of bupivacaine and low-dose meloxicam. Tetrodotoxin, a naturally occurring reversible site 1 sodium channel toxin derived from pufferfish and shellfish, has shown the potential to block conduction of isolated nerves. Neosaxitoxin is a more potent reversible site 1 sodium channel toxin also found in shellfish that can also block nerve conduction. These novel formulations show great promise in terms of the ability to prolong the duration of single injection PNBs. This field is still currently in development, and more researchers will need to be done to ensure the efficacy and safety of these novel formulations. These formulations could be the future of pain management if ongoing research continues to prove positive effects and low side effect profiles.

One of the main objectives in neurosurgical procedures is the prevention of cerebral ischemia and hypoxia leading to secondary brain injury. Different methods for early detection of intraoperative cerebral ischemia and hypoxia have been used. Nearinfrared spectroscopy (NIRS) is a simple, non-invasive method for monitoring cerebral oxygenation increasingly used today.

The aim of this study was to systematically review the brain monitoring with NIRS in neurosurgery. Data Sources: The search process resulted in the detection of 324 articles using valid keywords on the electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Study Selection: Subsequently, the full texts of 34 studies were reviewed, and finally 11 articles (seven prospective studies, three retrospective studies, and one randomized controlled trial) published from 2005 to 2020 were identified as eligible for systematic review.

Meta-analysis was not possible due to high heterogeneity in neurological and neurosurgical conditions of patients, expression of different clinical outcomes, and different standard reference tests in the studies reviewed.

The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings.

The potential for cancer cells to grow and to metastasize depends on complex interactions between inflammatory signals and pathways, immune cells, and elements of the stromal tissue in which they invade. Related to the nature of many cancers, the probability of recurrence can potentially be quite high for some patients. Immunology, lifestyle modifications, timing of disease, genetics, age, gender, and race are only a handful of ways the likelihood of cancer recurrence can be influenced. The quantity, or density, of certain immunological cells or factors, plays a role in the propagation of cancer cells. Opioids are often used in cancer patients for acute postoperative and chronic pain management. While they can produce significant pain relief, the type of analgesic utilized is important, as it may influence cancer propagation. In this regard, certain opioids have been found to increase T regulatory cells while suppressing NK cell function. Morphine may promote tumor neovascularization and expansion. Fentanyl administration significantly diminishes NK-cells and CD8+ cytotoxic T-cells. In a recent meta-analysis, propofol-based anesthesia improved both cancer-free survival and overall survival. COX inhibitors have also shown promise in persevering cancer immune function, as in literature involving ketorolac and celecoxib. In summary, inhaled anesthesia and opioids may contribute to a pro-tumor metastasis environment also known as cancer propagation; whereas propofol and COX inhibitors may provide a better alternative to reduce cancer recurrence and propagation.

This study aimed to investigate the relationship between depression and pain anxiety with pain catastrophizing in patients with coronavirus disease 2019 (COVID-19).

In this descriptive, correlational study, 180 patients with COVID-19 in Akhtar and Imam Hossein hospitals in Tehran, Iran, were included from March 2019 to April 2020. All participants completed three questionnaires, including the Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale (PASS), and Beck’s Depression Inventory (BDI). The data were analyzed using Pearson correlation coefficient and multivariate regression.

There was a positive and significant relationship between the dimensions of rumination, magnification, and helplessness with total score of pain catastrophizing, as well as moderate to severe dimensions with total pain anxiety and depression in patients with COVID-19.

According to the results of regression analysis, pain anxiety based on pain catastrophizing dimensions was statistically significant, so that rumination, magnification, and helplessness could predict pain anxiety and explain a total of 15.1% of changes in pain anxiety. Also, depression was statistically significant based on dimensions of pain catastrophizing, so rumination, magnification, and helplessness could predict the patients’ depression and explain 13.6% of depression changes.

Post spinal anesthesia hypotension (PSAH) is frequently encountered in anesthetic practice, especially during cesarean section. Ultrasound is a safe and easy technique for hemodynamic monitoring.

This study was conducted to assess the efficacy of pre-operative inferior vena cava collapsibility index (IVCCI) and internal jugular vein collapsibility index (IJVCI) in predicting PSAH.

This cross-sectional blinded study included 55 pregnant females prepared for elective cesarean section. They were divided into two groups based on the incidence of PSAH: (1) cases with PSAH (26 cases); and (2) cases without PSAH (29 cases). All the cases underwent ultrasound-guided measurement of IVCCI and IJVCI. The efficacy of these parameters was assessed in predicting PSAH.

Cases in both groups expressed non-significant differences regarding demographic data. However, IVCCI had mean values of 38.27 and 23.97%, while IJVCCI had mean values of 46.50 and 33.41%, respectively, in cases with and without PSAH. For IVCCI, using a cut-off point of 33% had sensitivity and specificity (84.6 and 93.1%, respectively) for predicting PSAH, with a diagnostic accuracy of 89.1%. IJVCI had sensitivity and specificity of 84.6 and 82.8%, respectively, for predicting the same complication using a cut-off value of 38.5%.

IVCCI and IJVCI are efficacious and reliable tools in predicting PSAH in pregnant ladies undergoing cesarean section, with a slight superiority for IVCCI regarding specificity and accuracy.

For pregnant women who require an emergency cesarean section (CS), extending labor epidural analgesia as quickly as feasible to good quality anesthesia is a critical issue. This indicates the presence of functional labor epidural analgesia and reduces the need for general anesthesia. Addition of magnesium increases anesthetic and analgesic qualities of epidural anesthesia.

The purpose of this trial was to assess the role of adding magnesium sulfate (MgSO4) with levobupivacaine to speed up the conversion of labor epidural analgesia into enough anesthesia for emergency CS.

Fifty parturients were randomly assigned to receive 19.5 mL of levobupivacaine 0.5% with either 0.5 mL of normal saline 0.9% (Group I) or 0.5 mL of MgSO4 10% (Group II) after receiving labor epidural analgesia. We documented the onset of block (loss of pinprick to T6), number of patients needing additional analgesia, the time needed for sensory and motor blockade to recover, and the adverse effects.

The frequency of patients receiving intraoperative supplements was comparable in the study groups (P = 0.491), although the onset of the block was faster in Group II than in Group I (P = 0.000*). Group II took substantially longer to recover from sensory and motor blockade than Group I (P = 0.001* and P = 0.001*, respectively). In both groups, the occurrence of adverse events was similar.

Adding 50 mg of MgSO4 to levobupivacaine 0.5% accelerated the epidural top, and both sensory onset and motor blocks period were prolonged as compared to levobupivacaine alone when extending epidural analgesia for emergency CS.

Clavicular fractures are commonly encountered in daily practice, and most cases are operated under general surgery. Until now, there has been a debate about the best approach to manage pain in such cases.

We aimed to evaluate whether ultrasound-guided clavipectoral block [clavipectoral fascial plane block (CPB)] would be safe and effective in cases with clavicular fractures.

This prospective randomized study included a total of 40 patients with clavicular fractures; they were divided into 2 groups. Group 1 included 20 cases who underwent CPB, and group 2 included 20 cases who underwent placebo block. Pain score, duration of analgesia, total analgesic consumption, and procedure-related complications were noted and recorded.

Despite the comparable demographic data between the 2 groups, pain scores were significantly lower in group 1 than in group 2, starting from postanesthesia care unit (PACU) admission until 12 hours after the operation. Group 1 showed a significant reduction in 24-hour opioid consumption and significant prolongation of the duration of analgesia compared to the placebo. Patient satisfaction was significantly better in group 1 than in group 2. No block-related adverse events were recorded.

CPB is a safe and effective regional technique that should be used for pain management after clavicular fixation surgery

Strabismus surgery and the use of opioid are risk factors of postoperative vomiting. We evaluated whether there is a dose-dependent effect of remifentanil on the incidence of postoperative vomiting.

Sixty pediatric patients who were scheduled for strabismus surgery were enrolled. Patients were randomly divided into three groups; Group H (high-dose remifentanil group), Group L (low-dose remifentanil group), and Group C (control group). After endotracheal intubation, patients in the Group H and L received an intravenous bolus dose of remifentanil of 1.0µg/kg and 0.5µg/kg over 2 min, respectively. Group H and L patients received a continuous infusion of remifentanil (0.1 µg/kg/min) during the surgery. The patients in Group C did not have any dose of remifentanil. Intravenous fentanyl (1 µg/kg) was administered to the patients for postoperative pain control.

The primary outcome was a difference of the incidence of postoperative vomiting within 24 hours after surgery. There was no significant difference in incidence of postoperative vomiting between three groups. The degree of emergence agitation and postoperative pain did not show any significant difference between three groups. The intraoperative administration of remifentanil did not show dose-dependent effect on postoperative vomiting in pediatric strabismus surgery

Postoperative cognitive dysfunction (POCD) is a complication that mainly occurs in adult patients and refers to a new-onset decline in cognitive function after anesthesia and surgery. The literature lacks evidence regarding opioid-free anesthesia and its impact on mental function postoperatively.

The effect of opioid-free anesthesia on POCD following urological surgery has not been previously reported. Accordingly, we present a case series of 15 adult patients undergoing transurethral urological surgery under general anesthesia using an opioid-free protocol with dexmedetomidine, ketamine, and lidocaine.

Patients that underwent simple transurethral elective urological procedures under general opioid-free anesthesia were included. This case series is part of a prospective clinical study regarding opioid-free anesthesia and served as a pilot sample. The mini-mental state examination (MMSE) test, performed preoperatively and 12 hours postoperatively, was applied to assess POCD.

Fifteen patients with a mean age of 68 years old were included in the study. The opioid-free protocol was associated with non-statistically significant changes of the MMSE test after minor urological procedures.

In our study, an opioid-free protocol of general anesthesia, using a mixture of dexmedetomidine, ketamine, and lidocaine, did not seem to have a negative impact on postoperative cognitive function in patients undergoing transurethral urological surgery. Further studies specifically designed to identify this effect are certainly required to further prove such an effect.

Due to the anti-inflammatory effects of dextrose prolotherapy, we evaluated the effectiveness of extra-articular, neurofascial dextrose prolotherapy in chronic ankle ligament injury.

Patients with chronic ankle ligament injury entered this uncontrolled before-after study based on eligibility criteria. Patients who consented to participate in the study filled out the prepared questionnaire containing demographic data, the Cumberland ankle instability tool (CAIT), and the Visual Analogue Scale (VAS). The initial CAIT score of less than 25 indicated functional instability following an ankle sprain. Patients underwent neurofascial prolotherapy with dextrose 12.5%. Two injections within one month were done. The CAIT was completed one, three, and six months after the intervention.

Twenty-five patients with chronic ankle ligament injury were investigated. The mean CAIT score was 1.88 (± 2.35) before the intervention, which increased significantly over the study (P < 0.001). The CAIT score reached 21.84 (± 6.04) in the sixth month after the intervention. Moreover, the VAS score decreased significantly over the study from 6.12 (± 2.35) before the intervention to 1.24 (± 0.43) in the sixth month after the intervention (P < 0.001).

Our findings revealed the therapeutic effectiveness of dextrose neurofascial prolotherapy in decreasing pain and functional instability in patients suffering chronic ankle pain due to ligamentous injury accompanied by chronic ankle instability

Pulsed radiofrequency (PRF) has been used for the treatment of chronic lumbar radicular pain and other chronic pain states. The dorsal root ganglion (DRG) consists of primary afferent somatic and visceral nerve cell bodies that transduce sensory signals from the periphery to the central part of the nervous system. It is a very important part of acute nociception, as well as the development and maintenance of chronic pain.

A total of seven domestic pigs were investigated. All pigs underwent a PRF procedure while under general anesthesia and with X-ray imaging. Four lumbar DRGs were randomly treated. We used the opposite side of the DRGs as controls. The lumbar region of the spine was placed in 10% formaldehyde for one month. After this fixation, DRG samples were prepared for slide analysis.

Nestin (Nes, code-Nr. AB 5968, dilution 1:250, rabbit, Abcam, United Kingdom) and matrix metallopeptidase 2 (MMP-2, codeNr. DUB 03, dilution 1:100, goat) expressions were detected by immunohistochemical staining. The cell numbers with Nes (28.4 ± 3.3 vs. 16.1 ± 3.4; P < 0.05) and MMP-2 (26.2 ± 3.2 vs. 14.1 ± 2.3; P < 0.05) expressions were larger on the PRF side compared to the control side. The glial cells in the spinal ganglia on both sides showed immunoreactivity.

The increase of MMP-2-containing gangliocytes one month after PRF procedures highlights active neural cell proliferation. Increased Nes factor expression in spinal gangliocytes of the lumbar region indicates neural remodeling and regeneration.

Glottic closure insufficiency increases the risk of aspiration and pneumonia, particularly in the elderly. Medialization thyroplasty is an open surgical procedure for treating glottic incompetency by approximating both vocal folds. The vocal fold medialization is achieved by inserting an implant to bring the nonmobile fold to the unaffected side. Lung isolation in patients with vocal cord implantation poses a unique challenge. Understanding the risks of differentmodalities of lung isolation and their impacts on the vocal cord implant is crucial to implementing a specifically tailored plan. Preoperative bronchoscopy, intraoperative video laryngoscopy, and bronchoscopy are ideal methods for assessing the vocal fold implants and guiding the lung isolation technique. Bronchial blocker through a single-lumen endotracheal tube may be the preferred choice to avoid the injury of the stretched vocal cords and dislodgement of the implant by a larger diameter double-lumen tube.

In patients under general anesthesia, the laryngeal mask airway (LMA) is a valuable alternative to endotracheal intubation to maintain the airway. In this study, we compared the efficacy of LMA with an endotracheal tube (ETT) in plastic and reconstructive surgeries over 2 h on thorax and abdomen under general anesthesia in Hazrat Fatemeh Hospital in Tehran, Iran, in 2020.

This randomized clinical trial was performed on a sample size of 80, randomly assigned to two groups. The main variables included the ease of placement, recurrent carbon dioxide content, arterial oxygen saturation, and laryngeal and tracheal spasm. In addition, the sub-variables entailed the mean duration of anesthesia, nausea and vomiting, sore throat, and abdominal distension. The obtained data were analyzed by the SPSS software version 25.

In the present study, 76 patients were female. Mean age, recurrent carbon dioxide, arterial oxygen saturation, laryngeal and tracheal spasm, the mean duration of anesthesia, nausea and vomiting, sore throat, and abdominal distension were not significantly different between the two groups.

The results of this study showed that the classic laryngeal mask could be used as a means of airway control in general anesthesia for long-term surgeries of more than 2 h.

Airway management is an important skill for emergency physicians, and confirmation of correct endotracheal tube (ETT) placement is a crucial component of airway management.

Due to the occurrence of incorrect ETT positioning in emergency departments, the present study aimed to compare the diagnostic sensitivity of ultrasound using suprasternal and subxiphoid methods for confirming the correct placement of ETT compared to capnography.

This cross-sectional study was conducted by examining patients requiring intubation. Ultrasound was performed by two independent emergency medical assistants using two suprasternal and subxiphoid methods to confirm correct ETT placement; the results were then interpreted. To observe the tube passage through the vocal cords, capnography and lung auscultation were applied as the gold standards, and the results of two ultrasound methods were compared.

A total of 66 patients, who were intubated in the emergency department, participated in this study. The positive and negative predictive values, sensitivity, and specificity of supernatural ultrasound were 96.72%, 80%, 98.33%, and 66.67%, respectively. Also, positive and negative predictive values, sensitivity, and specificity of subxiphoid ultrasound were 97.95%, 29.41%, 80%, and 83.33%, respectively. The diagnostic odds ratios of suprasternal and subxiphoid ultrasounds were 1.026 and 1.024 compared to capnography, respectively.

Ultrasonography using the suprasternal method was feasible. Considering the high sensitivity and specificity of this method in confirming correct ETT placement, it produced reliable results. Overall, this modality can be used as one of the main methods to verify correct ETT placement in emergency departments.

Coronary artery bypass grafting (CABG) surgery is a treatment option for coronary artery diseases. Cardiac arrhythmias during CABG surgery can lead to serious complications. Potassium ion concentration is a factor involved in such arrhythmias.

This study aimed to investigate the relationship between potassium concentration and cardiac arrhythmias in CABG surgery.

This descriptive cross-sectional study was performed on 60 patients with the American Society of Anesthesiologists class I, II, and III undergoing CABG surgery at Golestan Hospital, Ahvaz, Iran. All patients underwent general anesthesia, and ventilator control was achieved by mechanical ventilation. The on-pump method was used for CABG. Potassium levels were measured at several time points during surgery. All cardiac arrhythmias were recorded. Mean arterial pressure (MAP), serum level of potassium, blood sugar, blood urea nitrogen (BUN), creatinine, calcium, magnesium, hemoglobin (Hb), and sodium were also recorded.

The mean age of the patients was 60.87±7.35 years, and 45% of the subjects were female. Moreover, there was no statistically significant difference between the patients. There was a significant relationship between the changes in MAP, potassium, blood sugar, BUN, creatinine, calcium, and magnesium with the incidence of cardiac arrhythmias (P < 0.05). However, no significant relationship was noted between Hb and sodium levels with the incidence of cardiac arrhythmias (P < 0.05).

The changes in potassium levels increase the risk of cardiac arrhythmias and their complications.

Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks.

This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time.

In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI.

The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.521.83 vs 1.52.84 (P = 0.03) on the first day, 0.702.19 vs 1.582.86 (P = 0.05) on the second day, and 0.822.32 vs 1.182.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups.

In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.