Anesthesiology and Pain Medicine
Volume:11 Issue: 3, Jun 2021

This is a comprehensive literature review of chronic fatigue syndrome (CFS). We provide a description of the background, etiology, pathogenesis, diagnosis, and management regarding CFS. CFS is a multifaceted illness that has many symptoms and a wide array of clinical presentations. As of recent, CFS has been merged with myalgic encephalomyelitis (ME). Much of the difficulty in its management has stemmed from a lack of a concrete understanding of its etiology and pathogenesis. There is a potential association between dysfunction of the autoimmune, neuroendocrine, or autonomic nervous systems and the development of CFS. Possible triggering events, such as infections followed by an immune dysregulation resulting have also been proposed. In fact, ME/CFS was first described following Epstein Barr virus (EBV) infections, but it was later determined that it was not always preceded by EBV infection. Patient diagnosed with CFS have shown a noticeably earlier activation of anaerobic metabolism as a source of energy, which is suggestive of impaired oxygen consumption. The differential diagnoses range from tick-borne illnesses to psychiatric disorders to thyroid gland dysfunction. Given the many overlapping symptoms of CFS with other illnesses makes diagnosing it far from an easy task. The Centers for Disease Control and Prevention (CDC) considers it a diagnosing of exclusion, stating that self-reported fatigue for at minimum of six months and four of the following symptoms are necessary for a proper diagnosis: memory problems, sore throat, post-exertion malaise, tender cervical or axillary lymph nodes, myalgia, multi-joint pain, headaches, and troubled sleep. In turn, management of CFS is just as difficult. Treatment ranges from conservative, such as cognitive behavioral therapy (CBT) and antidepressants, to minimally invasive management. Minimally invasive management involving ranscutaneous electrical acupoint stimulation of target points has demonstrated significant improvement in fatigue and associated symptoms in a 2017 randomized controlled study. The understanding of CFS is evolving before us as we continue to learn more about it. As further reliable studies are conducted, providing a better grasp of what the syndrome encompasses, we will be able to improve our diagnosis and management of it.

Adjuvant drugs for peripheral nerve blocks are a promising solution to acute postoperative pain and the transition to chronic pain treatment. Peripheral nerve blocks (PNB) are used in the brachial plexus, lumbar plexus, femoral nerve, sciatic nerve, and many other anatomic locations for site-specific pain relief. However, the duration of action of a PNB is limited without an adjuvant drug. The use of non-opioid adjuvant drugs for single-shot peripheral nerve blocks (sPNB), such as alpha-2 agonists, dexamethasone, midazolam, and non-steroidal anti-inflammatory drugs, can extend the duration of local anesthetics and reduce the dose-dependent adverse effects of local anesthetics. Tramadol is a weak opioid that acts as a central analgesic. It can block voltage-dependent sodium and potassium channels, cause serotonin release, and inhibit norepinephrine reuptake and can also be used as an adjuvant in PNBs. However, tramadol’s effectiveness and safety as an adjuvant to local anesthetic for PNB are inconsistent. The effects of the adjuvants on neurotoxicity must be further evaluated with further studies to delineate the safety in their use in PNB. Further research needs to be done. However, the use of adjuvants in PNB can be a way to help control postoperative pain.

 Pain medicine fellowship applicants often seek information about programs from the Internet, which is becoming even more relevant with the transition to virtual interviews as a consequence of the global pandemic. Previous literature has revealed the significance of training program websites as part of the application process in other specialties.

 The objective of this cross-sectional study was to evaluate the content, design, organization, and user friendliness by using a composite score to determine the quality of the pain medicine fellowship websites (PMFW).

 Accredited pain medicine fellowship programs was queried from three databases for pain medicine education: (1) Electronic Residency Application Service (ERAS); (2) the Fellowship and Residency Electronic Interactive Database (FREIDA); and (3) the National Resident Matching Program (NRMP). Programs that appeared within one and/or more databases were eligible for study inclusion. PMFW were evaluated for the accessibility of recruitment and education content items. The quality of PMFW was determined as multifactorial composed of four dimensions: content, design, organization, and user friendliness.

 For program recruitment, PMFW contained an average of 12 ± 4.0 of 32 content items (38%) for fellowship programs: (1) 83% of fellowship programs specified the number of positions available for the 2021 Match; (2) 17% indicated alumni career placement; (3) 6.8% supplied interview dates; and (4) merely 4.9% detailed the selection process. For program education, PMFW contained an average of 7 ± 3.4 of 16 content items (44%): (1) 70% of programs provided a rotation schedule; (2) 49% detailed operative experiences; and (3) just 16% included simulation training. Regarding the quality based on content, design, organization, and user friendliness, the average PMFW was not “good” with only 1% of PMFW meeting “great” standards. A kappa value of 0.92 was calculated for inter-rater reliability.

 The web presence of pain medicine fellowship programs falls short of providing essential accessibility, content, design, organization, and user friendliness to allow applicants to adequately access information about program characteristics. There are ample opportunities to increase the effectiveness of PMFW to benefit training programs and to inform prospective applicants, especially given the rise of virtual applications and interviews.

 Reform in medical education is a basic process in every academic department, especially in residency programs.

 This study was designed to assess the indices of education and research as part of the Medical Education Reform program (MERP) in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU) for four years.

 MERP in DACC, SBMU was designed and implemented as a modern academic reform model; different outcome measures in education and research were assessed to demonstrate the effects of the reform plan in academic improvements.

 there were significant improvements regarding education indices (i.e., teaching methods, passing comprehensive exams, mentorship, assessment methods, faculty development, professionalism in medical education, integration in education, and crisis management) and research indices (targeted research activities, innovation in research approaches, increasing the impact of research).

 Based on the experiences of DACC, SBMU regarding clinical anesthesiology residency, reform could be achieved using painstaking plans and continuous efforts with tangible documented outcomes. Often, the management period is not durable, and these reforms require meticulous care to sustain.

The potential for misuse, overdose, and chronic use has led researchers to look for other methods to decrease opioid consumption in patients with acute and chronic pain states. The use of peripheral nerve blocks for surgery has gained increasing popularity as it minimizes peripheral pain signals from the nociceptors of local tissue sustaining trauma and inflammation from surgery. The individualization of peripheral nerve blocks using adjuvant drugs has the potential to improve patient outcomes and reduce chronic pain. The major limitations of peripheral nerve blocks are their limited duration of action and dose-dependent adverse effects. Adjuvant drugs for peripheral nerve blocks show increasing potential as a solution for postoperative and chronic pain with their synergistic effects to increase the duration of action and decrease the required dosage of local anesthetic. N-methyl-d-aspartate (NMDA) receptor antagonists are a viable option for patients with opioid resistance and neuropathic pain due to their affinity to the neurotransmitter glutamate, which is released when patients experience a noxious stimulus. Neostigmine is a cholinesterase inhibitor that exerts its effect by competitively binding at the active site of acetylcholinesterase, which prevents the hydrolysis of acetylcholine and subsequently retaining acetylcholine at the nerve terminal. Epinephrine, also known as adrenaline, can potentially be used as an adjuvant to accelerate and prolong analgesic effects in digital nerve blocks. The theorized role of sodium bicarbonate in local anesthetic preparations is to increase the pH of the anesthetic. The resulting alkaline solution enables the anesthetic to more readily exist in its un-ionized form, which more efficiently crosses lipid membranes of peripheral nerves. However, more research is needed to show the efficacy of these adjuvants for nerve block prolongation as studies have been either mixed or have small sample sizes.

 The prevalence of obesity is increasing worldwide, and anesthesiologists are facing challenges in the airway management of such patients. Excessive adipose tissue influences pharyngeal spaces and affects the laryngoscopic grade. Standard ramp positioning is time-consuming and difficult to prepare, and requires expensive equipment.

 The aim of this study was to compare the standard ramp position with the proposed low-cost and easily accessible modified ramp position in laryngoscopic view during the intubation of patients with morbid obesity.

 In this single-blind clinical trial, 84 patients candidate for bariatric surgery at Rasoul Akram Hospital in 2020 were assigned to the rapid airway management positioner (RAMP) (R) and new modified RAMP (MR) groups by the block randomization method. The laryngoscopic view of the glottis based on the Cormack-Lehane scale, ventilation quality, duration of intubation, intubation attempts, oxygen saturation at the end of intubation, and the need for backward, upward, rightward pressure (BURP) maneuver for successful intubation were recorded. Normal distribution tests and Mann-Whitney and Kruskal-Wallis tests were used to analyze the data.

 The results showed no significant differences between the two groups regarding ventilation score, laryngoscopy grade, number of intubation attempts, duration of intubation, and the need for BURP maneuvers during intubation (P > 0.05).

 The two methods are not significantly different, and the new modified ramp position can be used with more ease and availability and less cost.

 Peripheral glucocorticoid receptors (GRs) are altered by peripheral nerve injury and may modulate the development of neuropathic pain. Two central pathogenic mechanisms underlying neuropathic pain are neuroinflammation and N-methyl-D-aspartate receptor (NMDAR)-dependent neural plasticity in the spinal cord.

 This study examined the effect of the non-competitive NMDAR antagonist dextromethorphan on partial sciatic nerve ligation (PSL)-induced neuropathic pain and the spinal expression of the glucocorticoid receptor (GR).

 Male mice were randomly assigned into a sham group and two groups receiving PSL followed by intrathecal saline vehicle or dextromethorphan (iDMP). Vehicle or iDMP was administered 8 - 14 days after PSL. The hotplate paw-withdrawal latency was considered to measure thermal pain sensitivity. The spinal cord was then sectioned and immunostained for GR.

 Thermal hyperalgesia developed similarly in the vehicle and iDMP groups prior to the injections (P = 0.828 and 0.643); however, it was completely mitigated during the iDMP treatment (P < 0.001). GR expression was significantly higher in the vehicle group (55.64 ± 4.50) than in the other groups (P < 0.001). The iDMP group (9.99 ± 0.66) showed significantly higher GR expression than the sham group (6.30 ± 1.96) (P = 0.043).

 The suppression of PLS-induced thermal hyperalgesia by iDMP is associated with the downregulation of GR in the spinal cord, suggesting that this analgesic effect is mediated by inhibiting GR-regulated neuroinflammation.
 

 The cisterna Intrathecal Drug Delivery system (IDDS) with morphine has proven to be effective in treating refractory cancer pain above the middle thoracic vertebrae level in some countries. However, it has not been fully investigated in others. We designed the current project to investigate the efficacy and safety of cisterna IDDS for pain relief in refractory pain above the middle thoracic vertebrae level in advanced cancer patients.

 This study protocol allows for eligible cancer patients to receive the cisterna IDDS operation. Pain intensity (Visual Analogue scale, VAS), quality of life (36-Item Short-Form Health Survey, SF-36), and depression (Self-Rating Depression scale, SDS) are assessed along with side effects in the postoperative follow-up visits. Recent literature suggests a potential role for cisterna IDDS morphine delivery for refractory pain states above the middle thoracic level.

 The results of this study may provide further evidence that cisterna IDDS of morphine can serve as an effective and safe pain relief strategy for refractory pain above the middle thoracic vertebrae level in advanced cancer patients.

 This study aimed to assess the correlation between the internal jugular vein/common carotid artery (IJV/CCA) cross-sectional area (CSA) ratio and the inferior vena cava (IVC) diameter as non-invasive techniques for the assessment of intravascular volume.

 The study samples included 35 adult patients of both sexes (age range: 20 - 60 years) according to the criteria of the American Society of Anaesthesiology (ASA) physical status II - III, who were admitted to the surgical intensive care unit (SICU) after major surgeries for the assessment of intravascular volume status.

 There was a positive correlation between the IJV/CCA CSA ratio and the IVC maximum and minimum diameter before and after fluid infusion (r = 0.923, P < 0.001 and r = 0.390, P = 0.021, respectively) and between the IJV/CCA CSA ratio at inspiration and the IVC minimum diameter before and after fluid infusion (r = 0.605, P < 0.001 and r = 0.496, P < 0.001, respectively). The sensitivity and specificity analysis of the IJV/CCA CSA during inspiration after fluid correction to predict a central venous pressure (CVP) of 8 - 12 cmH2O showed that at a ratio of 2.56, the highest sensitivity was 56.5%, and the specificity was 83.3%; at a ratio of 2.58, the highest sensitivity was 65.2% and the specificity was 75%. During expiration, at a ratio of 2.62, the highest sensitivity was 52.2%, and the specificity was 67%; and at a ratio of 2.65, the sensitivity was 56.5%, and the specificity was 50%.

 The assessment of the IJV/CCA CSA ratio using bedside ultrasound could be a non-invasive tool for the evaluation of intravascular volume status in spontaneously breathing adult patients after major surgeries.

 The purpose of this study is a comparison of Valsalva, lidocaine, and Valsalva with administration of lidocaine to reduce the pain associated with administration of etomidate.

 The present study is a clinical trial study. The number of samples in each group was 30 and a total of 90 people were selected. This study was a clinical trial and the subjects were randomly divided into three groups: Group 1: Valsalva, 2: Lidocaine, 3: Valsalva and Lidocaine. Pain due to etomidate was rated on a VAS from 1 (painless) to 3 (worst imaginable pain) and their information was recorded. The collected information was entered into SPSS 22 and analyzed with appropriate statistical tests.

 A total of 90 subjects participated in the present study and were divided into 3 groups: Valsalva, lidocaine, and Valsalva with lidocaine. No significant difference was observed between demographic variables in the study groups. There was a significant relationship between severity of pain in the three groups. According to the results, the highest pain intensity was in the Valsalva group and the lowest pain intensity was in the Valsalva with lidocaine group.

 Valsalva with lidocaine reduces the severity of pain caused by etomidate to a greater extent than other groups.
 

 One of the most common devastating problems that occur after urethroplasty is erection, which causes surgical complications (fistula, wound dehiscence, and surgical graft failure) and the need for repairing the complications. We attempted to compare the effect of continuous epidural infusion of dexmedetomidine and ropivacaine as a post-surgical erection prevention strategy.

 In this study, we aimed to compare the effect of dexmedetomidine and ropivacaine epidural infusion on the incidence of erection after reconstructive urethral surgery.

 An RCT was conducted on 45 patients who were scheduled for reconstructive urethral surgery. They were randomly divided into three groups: (1) control (n = 15), (2) epidural dexmedetomidine (n = 15), (3) and epidural ropivacaine (n = 15). The control group received oral medication after surgery according to the conventional method (cyproterone compound tablets 50 mg BD and diazepam tablets 2 mg TDS for a week) to prevent erection. The DEX group received dexmedetomidine as continuous epidural infusion, and the ROP group received ropivacaine in addition to the conventional method. The occurrence of erection during day and night was recorded separately until the seventh day after surgery. Due to the long-time interval between case selection, participants from different groups were not matched with each other.

 The incidence of erection in the dexmedetomidine group was lower than that in the ropivacaine group per person (0.87) and significantly lower than in the control group (2.8 per person). Also, there was significantly less erection in the ropivacaine group (1.2 per person) than in the control group. Our study showed that erection after surgery significantly decreased with the continuous epidural infusion of dexmedetomidine and ropivacaine.

 Dexmedetomidine seems to have a significant preventive effect on erection after reconstructive urethral surgery.

Knee osteoarthritis (KOA) is the most common cause of chronic knee pain, and disability and different modalities have been used to improve pain and function. Botulinum toxin intra-articular injection is proposed to manage resistant joint pains.

This study was carried out to compare therapeutic effects of intra-articular botulinum neurotoxin (BTX) versus physical therapy (PT) in KOA.

In this single-blind randomized clinical trial, patients with KOA attending to Imam-Reza Hospital, Tehran, Iran, from June 2018 to March 2019 were enrolled. Patients who met the inclusion criteria were randomly divided into BTX receiving a single intra-articular dose of 100 units (250 units from disport brand) and PT groups. The study was described for patients, and informed consent forms were received. For assessment of the pain and related severity, the VAS score and KOOS scales were used. Post-intervention assessment was done 1, 3, and 6 months after the intervention. The level of significance was set at α = 0.05. All data analyses were performed with SPSS version 26 for windows.

In this study, 50 patients were randomly divided into BTX and PT groups. All patients completed the study, and there was no loss to follow-up. There was no significant difference between demographic data of the two groups, including age and BMI. The VAS score was similar in the two groups at the beginning. KOOS subscales were not significantly different, but the quality of life was better in the BTX than the PT group (86.2 ± 15 vs. 72.1 ± 11.5, P < 0.001). One month after the intervention, all KOOS subscales were improved in the BTX group in comparison to the PT group (P < 0.001). This difference was statistically significant in the 3rd (P < 0.001 in all comparisons except Sport/Rec subscale in which P = 0.02) and 6th months (P < 0.001) after the intervention, and the improvement in all KOOS subscales and VAS score were higher in the BTX group than the PT group. The trend of KOOS subscales and VAS score was improved over time in the BTX (P < 0.001 in all tests), but the PT group showed no improvement (P > 0.05) except for Sport/Rec and VAS score (P < 0.001).

Totally, it is concluded that the use of BTX can reduce pain and improve the function and quality of life in patients with KOA.

 Effective perioperative fluid therapy is a great consideration.

 Using lung ultrasound (LUS), this study evaluated the preference of the conventional and restrictive fluid replacement regimens for their volume impact in pediatric patients undergoing a relatively long procedure with limited volume loss (hypospadias repair).

 Eighty pediatric patients scheduled for hypospadias repair surgery were enrolled for conventional (CG) or restrictive fluid management groups (RG). The CG obtained Ringer's lactate at the conventional calculated doses, while the RG obtained infusion of Ringer's lactate at a rate of 3 mL/kg/h. B-line numbers in the LUS, recovery score, urine output, blood pressure (BP), heart rate HR, and oxygen saturation (SpO2) were recorded.

 As evidenced by the LUS, RG showed a higher incidence of normal lung morphology with a mean and SD of 1.3 ± 2.2 for B-line numbers, whereas, in CG, they were 3.1 ± 2.2 with a P-value < 0.001. Urine output was 3.2 ± 0.8 and 2.9 ± 0.7 for CG and RG, respectively, with a P-value equal to 0.07. HR, BP, and SpO2 differences between groups were statistically insignificant. The recovery score was higher in RG (5.8 ± 0.4) than in CG (5.1 ± 0.8) at the first postoperative 20 minutes, with a P-value < 0.001.

 In lengthy procedures with limited volume loss, using a moderately restrictive regimen is preferred over the conventional intraoperative fluid regimen considering both respiratory dysfunctions and recovery score.
 

 Interscalene block is one of the popular methods for decreasing pain and analgesic consumption after shoulder arthroscopic surgeries.

 The objective is to compare the analgesic duration of effects of dexmedetomidine and dexamethasone as adjuvants to 0.5% ropivacaine in ultrasound-guided interscalene blocks for arthroscopic shoulder surgery in an ambulatory setting.

 In this randomized controlled trial, 117 adult patients candidate for ambulatory arthroscopic shoulder surgery under general anesthesia were divided into three groups to perform an ultra-sound guided interscalene block before the surgery. The ropivacaine (control) group received ropivacaine 0.5% 20 mL, group Dexamethasone received ropivacaine 0.5% 20 mL plus 4mg dexamethasone, and group dexmedetomidine received ropivacaine 0.5% 20 mL plus 75 mcg of dexmedetomidine. Time to return of sensory function, of motor function, of first pain sensation, amount of opioid medication consumed at 24 hours and 48 hours post-operatively were measured.

 The 24-hour median (25th- 75th percentile) opioid consumption in morphine equivalents was similar between groups 22.5 mg (10 - 30), 15 mg (0 - 30), and 15 mg (0 - 20.6) in the ropivacaine, dexmedetomidine, and dexamethasone groups, respectively (P = 0.130). The median (25th- 75th percentile) 48 hours post-operatively, the median opioid consumption in morphine equivalents was 40 mg (25 - 67.5) in the ropivacaine group, 30 mg (22 - 50.6) in the dexamethasone group, and 52.5 mg (30 - 75) in the dexmedetomidine group (P = 0.278). The median 24-hour pain scores were 6 (5 - 8) in the ropivacaine control group, 7 (5.5 - 8) in the dexamethasone group, and 7 (4 - 9) in the dexmedetomidine group (P = 0.573).

 There was no statistical difference in opioid consumption at 24 and 48 hours post-operatively when comparing dexmedetomidine, dexamethasone, and no adjuvant. However, intraoperative opioid use was significantly lower with dexmedetomidine compared to dexamethasone and plain 0.5% ropivacaine. The safe side effect profile of dexmedetomidine makes it a reasonable alternative as an adjuvant for peripheral nerve blockade when dexamethasone use may be contraindicated.

 Patients under mechanical ventilation in the Intensive Care Unit (ICU) have a higher risk of delirium. To date, the ideal sedative combination for delirium treatment in terms of cost and side effects has not been determined.

 This study was designed to compare the effects of haloperidol and dexmedetomidine on delirium in trauma patients under mechanical ventilation in the ICU.

 Sixty patients with a moderate traumatic brain injury were randomly divided into two groups. Patients in the haloperidol group received 2.5 mg of haloperidol intravenously every eight hours for ten minutes daily, and the dexmedetomidine group received 0.5 µg/kg of dexmedetomidine via intravenous infusion every other day. Delirium, agitation, length of hospitalization, duration of mechanical ventilation, and need for sedation up to seven days were measured and recorded in both groups. The Richmond Agitation-Sedation scale (RASS) and Acute Physiology and Chronic Health evaluation (APACHE II) scales were used to determine the level of agitation in patients. The Confusion Assessment method (CAM)-ICU criteria were used to determine the incidence of delirium.

 Based on the results of this study, age and sex of the two groups were not significantly different. The mean age of the patients was 36.83 years in the haloperidol group and 40.1 years in the dexmedetomidine group. After the intervention, there was no significant difference in terms of the level of consciousness, number of days required for ventilation (P = 0.17), and number of days in the ICU (P = 0.49); however, there was a significant difference between the two groups three to seven days after the intervention. Besides, there was a significant difference between the two groups regarding the incidence of delirium five to seven days after the intervention (P < 0.05).

 There was a significant difference between the two groups in terms of the incidence of delirium and the level of agitation; the patients in the dexmedetomidine group were calmer and experienced less delirium.
 

 Hyperhidrosis is the maladjustment of excess sweating in specific parts of the body. Radiofrequency (RF) therapy has been successfully used to treat hyperhidrosis with a success rate of 85% - 95% in patients refractory to sympathectomy. The main hypothesis was the association between reduced palmar hyperhidrosis and radiofrequency RF therapy. The RF therapy is a less invasive technique, including the utilization of electromagnetic energy that is deposited near the nerve tissue. The mechanism of action of continuous RF could be explained by the destruction of afferent nerve fibers on their way from a nociceptive focus to the central nervous system. Pulsed RF was invented to explore this possibility, with the sole purpose of finding a less destructive and equally effective technique for the application of RF to afferent pathways. Herein, we further evaluated whether the procedure was safe without any complications in routine follow-up in palmar hyperhidrosis.

 Herein, we report the case of a male patient with an age of 22 years undergoing thermal RF sympathectomy therapy of thoracic T2 and T3 sympathetic ganglia for the palmar hyperhidrosis of his right hand observed for 3 months. The patient developed a contraction of the flexor involving the small muscles of the right hand with severe pain and congestion 17 days after the procedure without any other complications. The contraction was relieved by a sonar-guided median nerve block at the wrist with two injections of 2 mL lidocaine 2% and 2 mL dexamethasone.

 This study has been the first clinical case report complicated by the development of a contraction of the flexor muscles of the right hand with severe pain and congestion. The spasm was gradually relieved by sonar-guided median nerve injection at the level of the wrist and intended to assess the role of RF ablation with a success rate of 85% - 95% in palmar hyperhidrosis.

Context:

 Severe coronavirus disease 2019 (COVID-19) can induce acute respiratory distress, which is characterized by tachypnea, hypoxia, and dyspnea. Intubation and mechanical ventilation are strategic treatments for COVID-19 distress or hypoxia.

 We searched PubMed, Embase, and Scopus databases to identify relevant randomized control trials, observational studies, and case series published from April 1, 2021.

 24 studies were included in this review. Studies had been conducted in the USA, China, Spain, South Korea, Italy, Iran, and Brazil. Most patients had been intubated in the intensive care unit. Rapid sequence induction had been mostly used for intubation. ROX index can be utilized as the predictor of the necessity of intubation in COVID-19 patients. According to the studies, the rate of intubation was 5 to 88%. It was revealed that 1.4 - 44.5% of patients might be extubated. Yet obesity and age (elderly) are the only risk factors of delayed or difficult extubation.

 Acute respiratory distress in COVID-19 patients could require endotracheal intubation and mechanical ventilation. Severe respiratory distress, loss of consciousness, and hypoxia had been the most important reasons for intubation. Also, increased levels of C-reactive protein (CRP), ferritin, d-dimer, and lipase in combination with hypoxia are correlated with intubation. Old age, diabetes mellitus, respiratory rate, increased level of CRP, bicarbonate level, and oxygen saturation are the most valuable predictors of the need for mechanical ventilation. ICU admission mortality following intubation was found to be 15 to 36%. Awake-prone positioning in comparison with high-flow nasal oxygen therapy did not reduce the risk of intubation and mechanical ventilation. There was no association between intubation timing and mortality of the infected patients. Noninvasive ventilation may have survival benefits.

 Postoperative pain control after cardiac surgery is usually based on Opioids. These drugs are associated with side effects, and the use of drugs with fewer side effects is important for analgesia. Dexmedetomidine and paracetamol have fewer side effects than opioids.

 The aim of the study was to evaluate the adding paracetamol to dexmedetomidine continuous infusion pump for pain management after adult cardiac surgery.

 In this study, 100 patients were divided into two groups. One group received a continuous infusion of dexmedetomidine and paracetamol (DP), and the other received dexmedetomidine (D). These two groups were evaluated for MAP, HR, and the need for prescribing opioids before and after extubation. Also, duration of intubation and pain before extubation and 36 hours after every 4 hours.

 Patients in the DP group had lower mean MAP and HR during intubation period than the D group and needed fewer opioids and doses of opioids in addition to drug study infusion pre- (P = 0.001) and post-extubation (P = 0.001 and P = 0.022, respectively). The DP group patients were extubated earlier (P = 0.001). After extubation, the DP group had less pain than the D group.

 This study showed that adding paracetamol to the dexmedetomidine infusion pump can provide better analgesia.
 

 The proper management of postoperative pain improves patients’ quality of life, accelerates early postoperative recovery, shortens hospitalization period, and reduces medical costs. This study aimed to compare the effectiveness of intravenous fentanyl pump and sublingual buprenorphine tablet in controlling pain after open cholecystectomy.

 Evaluating the effectiveness of sublingual buprenorphine in reducing postoperative pain and complications after open cholecystectomy.

 This study was a double-blind, randomized clinical trial. The study population encompassed those candidates undergoing open cholecystectomy, patients with ASA class I and II, individuals undergoing no other concomitant surgery, and patients in the age range of 20 - 50 years. The first group received sublingual buprenorphine 6, 12, and 18 hours after the first administration. The second group received fentanyl as patient-controlled analgesia (PCA) for 24 hours. Then nausea, vomiting, sedation, and Visual Analog Scale (VAS) scores were evaluated at the beginning, 2, 6, 12, 18, and 24 hours after surgery. The collected data were analyzed using SPSS software version 20.

 The mean age of the patients in the buprenorphine and fentanyl groups were 44.8 ± 5.5 and 42.8 ± 7.1 years, respectively. In this study, 22.5% of the patients in the buprenorphine group and 35.5% of the patients in the fentanyl group were male. During 6 and 24 hours after surgery, the pain level regarding the VAS scores was significantly lower in the buprenorphine group than in the fentanyl group; however, analgesic consumption was higher in the fentanyl group. In the early hours after surgery (2 and 6 hours), nausea and vomiting were lower in the buprenorphine group than in the fentanyl group even though the difference was not significant.

 This study suggests buprenorphine as an effective drug for patients to reduce postoperative pain because of its limited complications, inexpensiveness, and more convenient administration method.