Anesthesiology and Pain Medicine
Volume:10 Issue: 1, Feb 2020

Context: Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against ‘aggressive’ measures. Evidence Acquisition: This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences.

As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other.

Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from ‘moderate, severe or worst’ pain.

Spinal anesthesia is the most common technique used for cesarean delivery due to some advantages compared to regional anesthesia. It is easily performed and provides a rapid onset of block. Though bupivacaine is a generally used long-acting amide type local anesthetic drug for spinal anesthesia, ropivacaine may sometimes be selected.

This prospective, randomized, double-blinded study was aimed at comparing clinical efficacy and safety between ropivacaine and bupivacaine during cesarean section.

After getting ethical committee approval and written informed consent, 65 women who referred to Imam Khomeini Hospital of Ahvaz, Iran in 2018 were chosen for elective cesarean delivery under spinal anesthesia. They were randomly allocated to receive either ropivacaine 1% (n = 33) or bupivacaine 0.5% (n = 32). Afterwards, the differences in the anesthetic efficacy, vital signs,
and hemodynamics of participants between the two groups were recorded.

Duration of sensory block was shorter in the ropivacaine group than bupivacaine group (132.521.6 min vs. 175.826.2 min; P < 0.001). Ropivacaine also produced a shorter duration of motor blockade than bupivacaine (124.820.2 min vs. 168.221.7 min; P < 0.001). There is no difference between the two groups in terms of systolic and diastolic blood pressure, but the heart rate
of patients in the bupivacaine group is significantly higher than the ropivacaine group.

The results suggest that ropivacaine and bupivacaine are two efficient drugs in anesthesia in the cesarean section, ropivacaine is a better choice due to little influence on the hemodynamics and shorter duration of sensory block and motor block which are useful for the recovery and also safe to the patients.

One-lung ventilation (OLV) is commonly used during thoracic surgery. At this time, hypoxemia is considered one of the remarkable consequences of the anesthesia management. Hypoxic pulmonary vasoconstriction (HPV) is the defense mechanism against hypoxia.

The aim of the present study was to investigate the effect of infusion of dexmedetomidine on improving the oxygenation during OLV among the adult patients undergoing thoracic surgery.

A total of 42 patients undergoing OLV by general anesthesia with isoflurane inhalation were randomly assigned into two groups: IV infusion of dexmedetomidine at 0.3 microgram/kg/h (DISO) and IV infusion of normal saline (NISO). Three Arterial Blood Gas (ABG) samples were obtained throughout the surgery. Hemodynamic parameters, PaO2, PaCO2, and complications at recovery phase were recorded. The collected information was analyzed using SPSS software version 22.

In the dexmedetomidine group, the mean hemodynamic parameters had a significant reduction at 30 and 60 minutes following OLV. Administration of dexmedetomidine resulted in a significant increase in the PaCO2 and a reduction in the PaO2 when changing from two-lung ventilation to OLV, where PaO2 reached its maximum value within 10 minutes after OLV in the DISO group, and it began to gradually increase to the end of operation. The duration of the recovery phase, also complications at the recovery phase decreased significantly in DISO group.

The results of the study showed that, dexmedetomidine may improve arterial oxygenation during OLV in adult patients undergoing thoracic surgery, and can be a suitable anesthetic agent for thoracic surgery.

Chronic pain is the third main problem of global health and the most common cause of long-term disabilities. The duration that patients suffer from chronic pain is directly proportional to the extent of the suffering and to the amount of health care resources allocated to this problem. There is no research that has studied the risk factors associated with the long pain duration in chronic pain patients.

We investigated the potential risk factors associated with long pain duration in a population with diverse pain conditions in a cross-sectional study. We used a questionnaire that included a number of potential risk factors including sex, age, marital status, household condition, number of children, employment, education, body mass index (BMI), pain intensity, and the level of anxiety/depression. The data were analyzed by univariable and multivariable linear regression models.

We recruited 780 patients. The analyses showed that age and abnormal BMI had a positive correlation with pain duration.

The risk factors that might be associated with longer pain duration include older age and abnormal BMI.

Electroconvulsive therapy (ECT) is a medical treatment most commonly used in the most severe psychiatric diseases; however due to unreal anxiety, it is not widely accepted by patients and their families.

The present study aimed to investigate the main causes of ECT-related anxiety (ERA) in an academic hospital in the north of Iran.

In this study, the participants were hospitalized psychiatric patients with proper communication skills. A 12-item questionnaire encompassing four sections (namely ECT side-effects, procedure factors, medical team communication, and familial, social, and economic factors) were filled out by a responsible psychiatric resident through a face-to-face interview. The participants’ demographic information, including gender, age, psychiatry disorder, level of education, and history of ECT, were also recorded.

In this study, 353 cases were analyzed, amongwhom329 patients (93.2%) reported at least one item for ERA, and 143 patients (85.6 %) had the history of ECT. All the participants (100%) had no experience in this regard (P = 0.0001). The most common cause of ERA was ECT-related side effects (70.7%) such as memory impairment (60.4%), disablement (24.9%), and death (14.7%) followed by procedure factors (27.2%), general anesthesia (GA) (73.2 %), and electric current (26.8 %). A significant relationship was observed between gender and the history of ECT with the patients’ anxiety reasons (P = 0.0001); however, the other variables, including age (P = 0.72), type of disease (P = 0.144), and the level of education (P = 0.012) had no impact on the results.

In this paper, the main causes of ERA were general anesthesia, memory impairment, and electric current. Obviously, a multidisciplinary approach is required to help these patients to handle their fear and anxiety successfully.

Background :

Pain is a major concern in the early postoperative phase after correction of pectus excavatum. Most studies only focus on pain management in the first days after surgery and describe methods to alleviate the pain immediately postoperatively. The severity of postoperative painmay be influenced by anxiety. So far, few studies have looked into the relationship between anxiety and postoperative pain after pectus excavatum correction. Objectives This study aimed to investigate the correlation between preoperative anxiety and late postoperative pain scores. 

Methods: 

This was a prospective cohort study. Anxiety was assessed with the State and Trait Anxiety Inventory questionnaire. Visual analogue scale (VAS) for pain scores assessed the pain at rest and activity. Anxiety was measured before surgery and pain scores six weeks after surgery. A hierarchical linear regression analysis was performed to investigate the correlation between baseline anxiety and pain measurements six weeks after surgery. Results In this study, 136 patients were included. State anxiety was not associated with postoperative pain (mean of pain on activity and in rest), only with pain on activity after six weeks. Age and sex were not effect modifiers in any of the models. Relevant confounding factors, although not significant, consisted of trait, sex, minor complications, epidural duration, major complications, and the number of stabilizer plates. The explained variance of state anxiety on VAS for pain scores was minimum after 6 weeks. Conclusions Preoperative anxiety does not appear to influence postoperative pain after PE correction.

Epidural steroid injection is a non-operative minimally invasive procedure for pain relief in spinal canal stenosis. However, there is no significant consensus regarding its efficacy.

In this study, we aimed to evaluate the effectiveness of translaminar injection of triamcinolone in lumbar canal stenosis.

In a retrospective study, we included 111 patients with MRI-confirmed spinal canal stenosis who were irresponsive to 12 weeks of conservative treatment and underwent epidural injection of triamcinolone through the translaminar approach. Outcome measures were routinely checked before the intervention and four weeks after the intervention, which included the Visual Analog scale (VAS) for low back pain, VAS for lower-limb pain, and Oswestry Disability index (ODI).

The study population included 32 (28.8%) males and 79 (71.2%) females with the mean age of 61 ± 13.4 years. The mean ODI, VAS for low back pain, and VAS for lower-limb pain significantly improved at the final evaluation session (P < 0.001, P = 0.001, and P < 0.001, respectively). The levels of improvement in ODI, VAS for low back pain, and VAS for lower-limb pain were considerably more in patients with single-level involvement (P < 0.001, P = 0.04, and P < 0.001, respectively). Improvement of lower-limb VAS was negatively correlated with age (r = -0.400, P < 0.001) and BMI (r = -0.525, P < 0.001). The ODI improvement was also negatively correlated with BMI (r = -0.569, P < 0.001).

Epidural injection of triamcinolone through the translaminar approach could be regarded as an efficacious method for the alleviation of pain and disability in patients with spinal canal stenosis.

Opioid use disorder, a major source of morbidity and mortality globally, is regularly linked to opioids given around the time of surgery. Perioperative period, however, is markedly heterogeneous, with the diverse providers using opioids distinctively, and the various drivers of opioid misuse at-play dissimilarly, throughout the perioperative period. The risk of opioid use disorder may, therefore, be different from opioids given at the various phases of perioperative care, and the ensuing recommendations for their use may also be dissimilar. Systematic search and analysis of the pertinent literature, following the accepted standards, showed an overall increased risk of misuse from the perioperative opioids. However, the analyzed studies had significant methodological limitations, and were constrained mainly to the out-patient phase of the perioperative period. Lacking any data, this risk, therefore, is unknown for intraoperative and postoperative recovery periods. Consequently, no firm recommendations can be extended to anesthesia providers generally managing these perioperative stages. Furthermore, with significant methodological limitations, the current recommendations for opioid use after surgery are also arbitrary. Thus, though proposals for perioperative opioid use are formulated in this article, substantive recommendations would require clear delineation of these risks, while avoiding the limitations noted in this review.

Pulsed radiofrequency (PRF) affects animal and plant tissues; however, the mechanism has not been defined. We hypothesized that the magnetic field produced by PRF exerts its effects by the magnetic sensitivity of transitions between spin states -a spin-correlated radical-pair mechanism (SCRPM)- which, in turn, affects the rates of chemical reactions with participation of paramagnetic species.

This study aimed to evaluate the effects of PRF on redox equilibrium and inflammatory status in a standard model of muscle injury in rats.

Twenty-four animals were subjected to a single impact trauma to the left quadriceps and the groups exposed and not exposed to PRF were compared. On day 7 of the experiment, the animals were killed and the quadriceps muscles were removed for analysis.

There was a significant increase in the concentration of thiobarbituric acid reactive substances (TBARS) in the muscle of animals from the trauma group (+233%), and this increase was eliminated by PRF administration. Superoxide dismutase (SOD) activity was increased (+411%) by trauma, resulting in significantly higher consumption of catalase (-72%), while PRF administration brought both of these markers back to levels close to those of the control group. Trauma induced considerable production of interleukins TNF-α, IL-1β, and IL-6 (+215%, +262%, and +326% vs. controls, respectively) and these effects were also significantly reduced by PRF administration.

In total, PRF inhibits oxidative stress and restores antioxidant enzymes to control levels and may block production of inflammatory markers in muscles of animals subjected to trauma. By modulating redox equilibrium, PRF treatment might block production of noxious mediators involved in development of trauma-induced injury.

Spinal anesthesia is used as a common anesthetic technique in many routine and outpatient surgeries.

The aim of this study was to determine the effect of phenylephrine on maternal hemodynamic changes during spinal anesthesia for cesarean delivery.

This double-blind randomized controlled trial was conducted on 116 pregnant women candidate for the elective cesarean section through spinal anesthesia in the Shahid Akbarabadi Hospital, Tehran in 2019. The eligible women were randomly divided into the intervention (phenylephrine; n = 58) and control (normal saline; n = 58) groups. The data collection tool was a checklist, including the demographic and clinical variables, such as age, height, weight, body mass index, gravid, gestational age, Apgar score of 1 and 5, systolic blood pressure, diastolic blood pressure, heart rate, mean arterial pressure, SPO2, PH of the umbilical cord, PCO2, HCO3, base excess, nausea, and vomiting. Data were analyzed using SPSS 24 software and P value < 0.05 was considered as significant.

The intervention and control groups showed a significant difference in terms of the PH of the umbilical cord, PCO2, and nausea and vomiting (P value < 0.05). The results of the repeated measure ANOVA test showed a significant statistical difference between the intervention and control groups at different time points in terms of arterial pressure, systolic and diastolic blood pressures (P value < 0.05).

Phenylephrine is effective in the prevention of some complications, like reducing mean arterial pressure, systolic and diastolic blood pressures, nausea, and vomiting during spinal anesthesia for cesarean delivery. Therefore, these drugs can be used based on maternal hemodynamic status during spinal anesthesia for cesarean delivery

Since a high neuraxial block is one of the serious complications in obstetric anesthesia, simulation training is required for the education of rapid diagnosis and treatment of this complication.

This study aimed to evaluate the effects of a simulation study of the high neuraxial block during epidural analgesia for labor pain on pre- and post-simulation tests in junior clinical trainees, who had graduated a medical school within one or two years and being under a two-month program for anesthesia during the Japanese Postgraduate Medical Education.

Twenty-two junior clinical trainees participated in this study from September 2016 to May 2017. Before the simulation training, the participants answered a pretest, providing written responses on “how to approach and treat the rapid spread of anesthesia (high neuraxial block) in painless epidural delivery” in a bullet-point form. The number of correct answers to 12 items was counted for each participant. These items were as follows: mask ventilation, preparation for tracheal intubation, oxygenation, supraglottic airway placement, checking the breathing, checking oxygen saturation using pulse oximetry, checking blood pressure, ephedrine injection, checking epidural tube, assessing the level of sensory block, assessing the level of consciousness, and left uterine displacement. After performing our original training, all participants were debriefed and written responses were obtained to a posttest containing the same content as the pretest.

The percentage of correct answers significantly increased from 8.3 to 16.7% (P = 0.041) after training. The response rates for “mask ventilation” and “check epidural tube” significantly increased from 13.6 to 54.5% (P = 0.004) and from 4.5 to 27.3% (P = 0.039), respectively, after training.

Simulation training is likely an effective method for junior clinical trainees on studying diagnosis and treatment of high neuraxial block during epidural analgesia in parturient patients.

Spinal cord stimulation (SCS) is an effective treatment option to relieve chronic intractable pain, and failed back surgery syndrome (FBSS) is a key indication.

The objective of the current study was to analyze the cost consequences of using non-rechargeable (NR)-SCS and rechargeable (R)-SCS.

Real data taken from a review of 86 patients were used to simulate costs and review which patients might have benefitted more from R-SCS. Calculations were made to see what is the impact from a monetary point of view.

On average, NR-SCS devices lasted for 58 months (M). Only 14 patients were not eligible to receive an R-SCS implant. We found that using R-SCS batteries would save up to €56.322 on average over a patient’s life expectancy, which means a saving of 43% compared to using NR-SCS systems. In our analysis, we found that if R-SCS implants were used instead of NR-SCS batteries, a saving of €5,735,334.23 over patients’ life expectancy would be made, which represented a 63% saving to the public health system. We found that R-SCS was cost-beneficial from second year compared to NR-SCS, saving up to 70% when patients are implanted for 9 years.

This cost-consequences analysis suggests that R-SCS implants are more cost-beneficial than NR-SCS systems in wellselected patient candidates for this type of treatment