Effects on ondansetron of postdural puncture headache after cesarean section under spinal anesthesia.

Background: Spinal anesthesia is commonly performed for cesarean section, however, postdural puncture headache (PDPH) is one of its most common adverse effects. Ondansetron is an antiemetic for cancer treatment and analgesia-induced nausea and vomiting. In this study, the authors aim to evaluate the effect of postoperative ondansetron on PDPH. Methods: In this randomized controlled clinical trial study, 120 pregnant patients are ASA ll, undergoing elective cesarean section, were randomized into two groups (placebo or study). The patients in the study group, immediately after the birth of a baby and 24 h after the operation, received ondansetron 4 mg IV while the placebo group received a placebo. The severity and incidence of headache, postoperative nausea and vomiting, dizziness, neck and lower back pain, and the use of analgesia was assessed in the two groups. Results: The significant meaning of the time effect (P<0.001) indicated that regardless of the group, for each unit increase in time, the chance of developing a headache increased by 23%, which was statistically significant. Also, the significant meaning of the group effect indicated that regardless of time, patients who did not take indomethacin had ~4.11 times higher chances of developing a headache compared to those who received the medication, which was statistically significant (P=0.004). Conclusion: The administration of ondansetron significantly reduces the occurrence of postspinal anesthesia headaches and neck pain. There was no significant difference in headache severity between the two study groups.

Assessing Blood-Brain Barrier Function in the Context of Pain Management.

One essential component of the neurovascular system is known as the blood-brain barrier (BBB). This highly effective biological barrier plays a pivotal role in regulating the brain's internal microenvironment and carefully controlling the passage of various chemicals into and out of the brain. Notably, it serves as a safeguard for the brain, particularly when it comes to the selective transportation of drugs like opioids and non-steroidal anti-inflammatory medications (NSAIDs), which are commonly used in the management of chronic pain. It's important to note that during the development of chronic pain, the activation of microglia and astrocytes can potentially disrupt or damage the integrity of the BBB. In this comprehensive review, we aim to delve into the intricate interplay between the blood-brain barrier and the transportation of pain-relieving drugs, shedding light on the challenges and mechanisms involved in this process.

Hemodynamic stability during menstrual cycle in women undergoing elective surgery.

Objective: Hemodynamic changes occur in almost one-third of patients undergoing spinal anesthesia, which are likely to effect vital organ. The aim of this study is to determine the hemodynamic effect of spinal anesthesia during different phases of menstrual cycle. Methods: This is a descriptive cross-sectional study, two hundred and seventy-three patients who underwent spinal anesthesia for elective surgery were enrolled in this study. Of all the patients, 141 patients were in the luteal phase and 132 patients were in the follicular phase of their menstrual cycle. Analytical epidemiological study was conducted using questionnaires. Blood pressure and heart rate of patients before, immediately after, and 1 h after spinal anesthesia were recorded, and the data were analyzed using SPSS software. Results: In the follicular phase before anesthesia, systolic blood pressure (SBP) was 127.5 ± 3.9, diastolic blood pressure (DBP) was 80.3 ± 6.2 mmHg and heart rate (HR) was 82.0 ± 8.5bpm, while, immediately after the induction of anesthesia following recordings were measured; 109.7 ± 9.13, 71.8 ± 2.8 mmHg and 70.0 ± 8.10bpm, respectively. In the luteal phase, it was 126.9 ± 3.12, 81.6 ± 9.3 mmHg and 80.2 ± 4.4bpm, and 122.0 ± 9.12, 78.6 ± 8.5 mmHg and 75.9 ± 6.5bpm respectively before and immediately after anesthesia, these changes in the menstrual phase was significant (P < 0.001). In the follicular phase an hour after spinal anesthesia, the mean SBP was 100.3 ± 3.9, DBP was 71.2 ± 7.5, MAP was 87.0 ± 4.7 mmHg and HR 67.5 ± 5.7bpm and following was seen in luteal phase; 115.4 ± 1.8, 75.9 ± 2.3, 97.3 ± 3.5 mm Hg and 74.0 ± 7.4bpm, respectively. These values were significantly lower in the follicular phase (P < 0.001). Conclusion: Spinal anesthesia in the luteal phase as compared to the follicular phase of the menstrual cycle shows less variation in hemodynamic parameters.

The Effect of Ginger on Postoperative Nausea and Vomiting Among Patients Undergoing Upper and Lower Limb Surgery: A Randomized Controlled Trial.

PURPOSE: Postoperative nausea and vomiting is one of the most common side effects associated with anesthesia. The aim of this study is to determine the effect of ginger on severity and incidence of nausea and vomiting after lower and upper limb surgery. DESIGN: This was a triple-blinded clinical trial. METHODS: Sixty eligible patients were randomly assigned to the intervention and control groups. The intervention group received four 250 mg ginger capsules and the control group received four placebo capsules 2 hours before surgery. Incidence and severity of nausea and vomiting immediately after the surgery and 2, 4, 6, and 8 hours after the surgery were evaluated. FINDINGS: The results of this study showed that the use of ginger capsules significantly reduces the incidence and severity of postoperative nausea and vomiting at different hours after surgery compared to placebo, P < .05, irrespective of the gender and the age of the patients. CONCLUSIONS: Use of ginger is effective in decreasing postoperative nausea and vomiting. However, further studies in comorbid patients are required to verify these outcomes.

Evaluating memory dysfunction after spinal anesthesia among patients undergoing elective surgery: Descriptive-analytical study.

BACKGROUND: Anesthesia has a number of side effects including cognitive impairment after the surgery. Postoperative cognitive impairment is commonly associated with general anesthesia. OBJECTIVE: The aim of this study is to evaluate the effects of Marcaine (bupivacaine hydrochloride) in memory impairment among patients undergoing elective surgery. MATERIALS AND METHODS: In this study descriptive-analytical study, patients undergoing elective lower extremity or lower abdomen surgery requiring spinal anesthesia were included. Following 24 h of the surgery, standard Wechsler questionnaire was used to assess memory of the patients. Other demographic and clinical parameters such as age, gender and blood pressure, pulse rate were also recorded. The obtained data was analyzed using SPSSv18. RESULTS: In this study, 105 patients where 55 (52.4%) males and 50 (47.6%) females were studied. The mean age of the subjects was 35.73 ± 10.64 years. There was a significant difference between the mean of memory scores in terms of logical memory and overall memory (P < 0.001). There was a significant relationship between the mean scores of patients' rational memory and systolic blood pressure at admission (P = 0.030). There was a significant relationship between mean associative learning scores in patients and systolic blood pressure at admission (P = 0.046) and type of surgery (P = 0.013). Furthermore, overall memory scores were significantly associated with age (P = 0.041). CONCLUSION: Based on the results of this study, it can be concluded that spinal anesthesia had a significant effect on some areas of memory. Further studies in this area can yield more reliable results.

Effects of ADJUVANT Ketamine on Induction of Anesthesia for the Cesarean Section.

BACKGROUND: The cesarean section has shown an increasing trend within the past few years. The use of appropriate and effective anesthesia for the procedure is important, not only to reduce the incidence of maternal and fetal morbidities but also to reduce the incidence of intraoperative consciousness. The aim of this study is to evaluate the intraoperative and postoperative effects of adjuvant ketamine, when used in combination with general anesthesia. METHODS: The study was conducted on the patients referred to Asali hospital for the cesarean section. 100 patients were assigned into two groups. Patients in Group A received thiopental (4 mg / kg) as an anesthetic agent for the surgery, whereas those in group B received thiopental along with 0.5 mg/kg of intravenous ketamine. The effects of ketamine, such as depth of anesthesia, intraoperative and postoperative awareness, vomiting and hallucination were recorded in the questionnaire and data were statistically analyzed using SPSS v25. RESULTS: Of 100 patients in group A, 10 of them were not deeply unconscious. 40 patients in group A and 25 in group B had intraoperative awareness. Depth of anesthesia was significantly associated with the use of ketamine (p = 0.0017) 1 patient in group A and 3 in group B had vomiting and 1 patient in group B was presented with the hallucinations. These parameters were not significantly associated with the dose of ketamine (p = 0.5). CONCLUSION: Overall use of ketamine is associated with better sedation and no significant side effects, with low doses of ketamine, were seen in our study. Comparative studies using other analgesics, with larger sample size, are therefore recommended.

The Effects of Magnesium Sulfate with Lidocaine for Infraclavicular Brachial Plexus Block for Upper Extremity Surgeries.

Background An addition of analgesic to anesthetic agents is likely to increase the effects of anesthesia and reduce associated adverse outcomes. Several adjuvants are studied in this regard. The aim of this study is to investigate the effects of adding a magnesium adjunct to lidocaine for the induction of infraclavicular block. Methods Patients referred to Shohada Ashayer Hospital, Khorramabad, for wrist and hand surgery were enrolled in this study. The intervention/case group included patients who received 18 mL lidocaine (2%) + 2 mL magnesium sulfate (50%), 10 mL normal saline; control group: 18 mL lidocaine (2%) + 12 mL of normal saline. After the induction of ultrasound-guided infraclavicular block, parameters such as duration of reach with respect to complete sensory and motor block, hemodynamic parameters (hypotension and bradycardia), and postoperative pain, using visual analogue scale criteria, were measured. The obtained data were analyzed using a Bayesian path analysis model. Results A total of 30 patients were included in each group. In the case group, sensory and motor block was achieved for 12.136 ± 4.96 and 13 ± 3.589 minutes more than those in the control group. The duration of sedation and immobilization was 2.57 ± 0.764 minute and 4.66 ± 0.909 minutes lengthier in the case group. Regarding the hemodynamic parameters, blood pressure was 0.217 ± 5.031 and 1.59 ± 5.14 units lower in the case group, immediately following the block and the surgery. Similarly, heart rate was 0.776 ± 4.548 and 0.39 ± 3.987 units higher in the case group, after 30 minutes and 2 hours of the procedure. A decrease in the pain was seen at 8, 10, and 12 hours after the surgery, as compared with the control group. An addition of magnesium to lidocaine for infraclavicular block resulted in a significantly longer sedation and immobilization period and decreased postoperative pain at 12 hours. Conclusion Heart rate and blood pressure did not decrease significantly in the case group. It can be concluded that addition of magnesium sulfate to lidocaine can produce better anesthetic and analgesic outcomes with low-to-no adverse effects.

The effect of the Iranian health transformation plan on hospitalization rate: insights from an interrupted time series analysis.

BACKGROUND: Healthcare policy- and decision-makers make efforts to build and maintain high-performing and effective health systems, implementing effectiveness programs and health reforms. In May 2014, the Iranian Ministry of Health and Medical Education has launched a series of ambitious reforms, known as the Health Transformation Plan (HTP). This study aimed to determine the effect of the HTP on hospitalization rate in Iranian public hospitals affiliated to the Ministry of Health and Medical Education. METHODS: This study was designed as a quasi-experimental, counterfactual study utilizing the interrupted time series analysis (ITSA), comparing the trend of hospitalization rate before and after the HTP implementation in 16 hospitals in the Lorestan province. Data was collected from March 2012 to February 2019. RESULTS: In the first month of the HTP implementation, an increase of 2.627 [95% CI: 1.62-3.63] was noted (P < 0.001). Hospitalization rate increased by 0.68 [95% CI: 0.32-0.85] after the HTP implementation compared to the first month after the launch of the HTP (P < 0.001). After the HTP implementation, monthly hospitalization rate per 1000 persons significantly increased by 0.049 [95% CI: 0.023-0.076] (P < 0.001). CONCLUSIONS: The HTP implementation has resulted in an increased hospitalization rate. Health planners should continue to further improve this service. ITSA can play a role in evaluating the impact of a given health policy.

Promethazine and Oral Midazolam Preanesthetic Children Medication.

AIMS: Several kinds of drugs have been investigated in preschool children as a preanesthetic sedation after various routes of administration for surgeries. This study aims to compare the efficacy of promethazine and oral midazolam for premedication in children aged 3 to 9 years who were scheduled for surgeries. METHODS: This is a double-blind randomized controlled study conducted on 93 patients between the age of 3 and 9 years at Loresten University of Medical Sciences Teaching Hospital, Khoramabad, Iran. The subjects were grouped into P (promethazine), M (midazolam), and C (control). About 0.3 mg/kg of oral promethazine was administered to patients in group P, 0.5 mg/kg of oral midazolam was administered to patients in group M, and 3 mL of normal saline as placebo was administered to patients in group C. Patient satisfaction, sedation and emotional score, systolic blood pressure (SBP), diastolic blood pressure, respiratory rate (RR), and heart rate (HR) were recorded. RESULTS: There was no statistically significant difference among the 3 groups. However, the period after medication, it was observed that SBP, diastolic blood pressure, RR, and HR in group C were statistically significantly higher than those in groups M and P. These 2 groups are similar in terms of SBP, RR, and HR. The emotional scores were comparable for the 2 groups. It was between 3.97 ± 0.6 to 1.7 ± 0.5 in group M and from 3.45 ± 1.17 to 2.745 ± 0.997 in group P in a Kruskal-Wallis test. CONCLUSIONS: This study shows that both test groups reduce stress at the time of anesthetic induction and separation from their parents with similar effect. Both of the anesthetics are easily administered without the necessity of an additional equipment. A shorter period to maximal sedation for midazolam is an advantage, thus, making the drug helpful, mostly in the outpatient setting.

The Effects of Caressing and Hugging Infants to Manage the Pain during Venipuncture.

The aim of this study is to investigate the effects of caressing in infants for pain management during venipuncture. This is a randomized control trial, carried out on 120 infants between 2 and 6 months of age, that included 30 males and 30 females in the hugging and control group, respectively. Parameters such as percentage blood saturation of blood, crying, and the duration of pain felt was evaluated. The venipuncture between the control and experimental groups showed that, less pain is felt by females when caressed by their mother. However, this difference does have statistical significance. Overall, caressing in infants had positive effect on pain-relief after venipuncture.

Comparative Study of 0.2% Glyceryl Trinitrate Ointment for Pain Reduction after Hemorrhoidectomy Surgery.

Context Hemorrhoid is one of the most common diseases in both, men and women, affecting half of the world's population over the age of 50. Aims The aim of this study was to evaluate the analgesic effects of local ointment of glyceryl trinitrate ointment (GTN) after hemorrhoidectomy. Methods and Materials In this randomized double-blind, placebo-controlled study, the patients were grouped as the treatment, that is GTN, and placebo (P) group. After surgery, 0.2% gelatin GTN ointment (250 mg), and P ointment ( n = 20 for each group) were applied topically on 1 cm on the anus using a standard ruler, three times a week in respective groups. visual analog scale was used to assess the intensity of the pain and complications of the drugs were observed at 6, 12, 18, and 24 hours. Statistical Analysis Used Data and questionnaires were analyzed statistically using SPSS17 software and results were recorded in the tabular form. Results Six hours after the application of the ointment, no significant difference was found among the groups, however, after 12, 18, and 24 hours significant reduction in pain was seen in GTN group, which was least after 18 hours. The mean values of the total pain score in the first 24 hours after surgery in the GTN group were 3.15 and 5.45 in the P group which were statistically significant. Nonetheless, headache was significantly increased in the GTN group. Conclusion Simple and safe topical GTN ointment can reduce the pain after hemorrhoidectomy, leading to the reduced need of other analgesics.

Comparison of the Mean Minimum Dose of Bolus Oxytocin for Proper Uterine Contraction during Cesarean Section.

BACKGROUND: Cesarean section is the most common midwifery operation. The aim of this study is to determine the mean minimum dose of bolus oxytocin for proper uterine contraction during cesarean section. METHODS: Patients were divided into two groups: elective cesarean section (n=41) and cesarean section due to difficulty in labor (n=42 patients). Patients underwent spinal anesthesia and oxytocin infusion was begun at 30 drops per minute (20 units of oxytocin per 1000 cc serum), and was also administered as a half-dose in cc to achieve effective contraction of the uterus. Meanwhile, the information of patients including systolic and diastolic blood pressure (SBP and DBP), heart rate and amount of bleeding during the operation was recorded in a questionnaire. RESULTS: In the elective cesarean section group, the average SBP was about 117.10mmHg, average DBP 70.50 mmHg, the amount of bleeding during surgery was 623.63mL, and heart rate was 88.88bpm. In the cesarean section group due to difficulty in labor progress, SBP was 113.5 mmHg, DBP 62.69 mmHg, and bleeding was 573.81mL. In addition, 9 patients in the elective group and 3 patients in the lack of progress group, did not require bolus oxytocin. In the lack of a progress group, 8 patients needed more than 5 doses of oxytocin. In addition, about 10 (12%) of all patients had no side effects, and hypotension. CONCLUSION: Given that, the minimum effective dose of oxytocin in the elective cesarean section was 1IU, and in those in labor progress was 1-1.5IU, less oxytocin administration represents lesser side effects. It is recommended that patients who are candidates of cesarean section should be administered 1.5IU of oxytocin in the form of bolus.

Pain management using nanotechnology approaches.

The proper treatment of pain is yet a major medical challenge. To obtain a long-term analgesia action, opioid therapy is the gold standard therapy for overcoming a chronic pain. Nanotechnology focus on formulating therapeutic agents encapsulated in a biocompatible nanocarriers (∼10-200 nanometer), these include but not limited to nanoparticles, liposomes and nanocapsules, micelles, dendrimers and nanotubes. This review gives an overview of current strategies of pain treatment with the help of the knowledge of nanotechnology. In addition, the applications of nano-innovation in oxidative therapy, genotoxicity and immunogenicity, are elucidated.

Effect of Encapsulated Artemisia aucheri. L Magnetic Nanogel Extract on Shoulder Block in Rat.

INTRODUCTION: Due to the severe pain generated after shoulder surgery, we aim to formulate and intravenously (IV) inject magnetic nanogel encapsulated Artemisia aucheri. L extract for inducing shoulder block in the rat. METHODS: Artemisia aucheri. L extract encapsulated magnetic nanoparticles (MNPs) was fabricated and tested in rat using paw withdrawal latencies (PWL) from thermal stimuli on the forepaw. The animals were divided into two groups; the untreated left forepaw (control group), and the test group with treated right forepaw. Sixteen (16) lab animals were used in this study, of which 3 in each of the two groups of the cumulative drug release experiments at 37°C and 43°C, and 5 in each of the two groups of PWL experiments. RESULTS: UV spectroscopy data shows that decreasing the pH of the fabricated nanocomposite has an influence on the extract release rate than increasing its temperature. CONCLUSIONS: The present study gave a proof of inducing a shoulder block in rat by IV injection administration of NIPAAM-MAA/Arthemisia aucheri. L extract complexes and magnet application to the shoulder. This will be a prospective formulation if a lower pH and temperature is considered for optimum release of this nanoanesthetics, thus, this can be translated into clinical practice for future applications.

Effect of Local Ropivacaine on Hemodynamic Responses in Craniotomy Patients.

BACKGROUND: Increased intracranial pressure (ICP) with hemodynamic is of major concern to anesthesiologists and surgeons in craniotomy surgery. Thus, the management of hemodynamic stability is essential in neuro-anesthesia. This study was performed to investigate the effect of local infiltration of 0.5% ropivacaine on hemodynamic responses in craniotomy patients. MATERIAL AND METHODS: 64 ASA class I -II patients, scheduled for elective craniotomies, were enrolled in this prospective randomized double blind placebo controlled study. These patients were randomly divided into the ropivacaine group, who were administered with 0.5% ropivacaine (n = 32), and the placebo group administered with 0.9% normal saline (NaCl) (n = 32). Anesthesia was induced with 3 µg/kg fentanyl, 5 mg/kg thiopental and 0.5 mg/kg atracurium, and was maintained with isoflurane (0.8-1 = MAC) in 50% N2O, 1 mg/kg /30 minutes, 40% oxygen and 0.05 mg/kg /hour fentanyl. Five minutes prior to surgery, 10 mL of 0.5% ropivacaine was injected in the line of skin incision in the ropivacaine group, while 10 mL of normal saline was injected in placebo group. Thereafter, the systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressures (MABP), and heart rate (HR) were measured before infiltration into the incision area, 30 seconds, 3 minutes, 5, 10, and 30 minutes after infiltration into the scalp. For higher BP and HR, an adjunct 0.5 mcg/kg of fentanyl was prescribed and administered. RESULTS: A significant difference was observed for SBP, DBP, MABP and HR, between the two groups at different times during craniotomy (p < 0.05). A significant decrease was observed for SBP, DBP, MABP and HR during craniotomy in 0.5% ropivacaine group as compared with placebo group (p < 0.05). CONCLUSION: Local anesthetic of 0.05% ropivacaine scalp infiltration is effective in clinical usage of regional anesthesia for producing good quality anesthesia, it seems to be a significant choice for management of optimal hemodynamic profile, providing a better hemodynamic stability during craniotomy.

Bupivacaine Versus Liposomal Bupivacaine For Pain Control.

Local infiltrations and regional blocks have been some of the effective ways employed to manage and control post-operative pain. One of the limitations of administration of local anesthesia drugs in post-operative conditions is its inability to act for a longer period of time. Multi-vesicular liposomes made up of bupivacaine have been progressively used for their increased duration of action. Compared to bupivacaine HCL, local infiltration of liposomal bupivacaine have shown to have a significantly increase the duration and delay in peak plasma concentration. In this article, we attempt to compare liposomal bupivacaine and bupivacaine based on available clinical literatures. Liposomal bupivacaine has been demonstrated to have promising implications in post- operative pain control resulting in increased patient satisfaction; reduced hospital admission and opioid induced adverse events. Clinical studies have identified liposomal bupivacaine to be effective in delivering increased post-operative pain control. The purpose of this review is to give a comprehensive comparison between bupivacaine liposomal and conventional bupivacaine based on reported clinical trials.

New Updates Pertaining to Drug Delivery of Local Anesthetics in Particular Bupivacaine Using Lipid Nanoparticles.

Lipid nanoparticles (liposomes) were first described in 1965, and several work have led to development of important technical advances like triggered release liposomes and drug-loaded liposomes. These advances have led to numerous clinical trials in such diverse areas such as the delivery of anti-cancer, antifungal, and antibiotic drugs; the delivery of gene medicines; and most importantly the delivery of anesthesia drugs. Quite a number of liposomes are on the market, and many more are still in developmental stage. Lipid nanoparticles are the first nano-medicine delivery system to be advanced from laboratory concept to clinical application with high considerable clinical acceptance. Drug delivery systems for local anesthetics (LAs) have caught the interest of many researchers because there are many biomedical advantages connected to their application. There have been several formulation techniques to systemically deliver LA that include encapsulation in liposomes and complexation in cyclodextrins, nanoparticles, and to a little extent gold nanoparticles. The proposed formulations help to decrease the LA concentration utilized, increase its permeability, and most importantly increase the localization of the LA for a long period of time thereby leading to increase in the duration of the LA effect and finally to reduce any local and systemic toxicity. In this review, we will highlight on new updates pertaining to drug delivery of local anesthetics in particular bupivacaine using lipid nanoparticles.

The effects of religion and spirituality on postoperative pain, hemodynamic functioning and anxiety after cesarean section.

Spiritual elements play an important role in the recovery process from acute postoperative pain. This study was conducted to assess the effect of pray meditation on postoperative pain reduction and physiologic responds among muslim patients who underwent cesarean surgery under spinal anesthesia. This double-blinded randomized clinical trial study was conducted among muslim patients who underwent cesarean surgery under spinal anesthesia during 2011-2013 at tertiary regional and teaching hospital in Lorestan, Iran. The patients were randomly divided into interventional group (n=80) and control group (n=80). For about 20 minutes using a disposable phone mentioned and listened to pray meditation "Ya man esmoho davaa va zekroho shafa, Allahomma salle ala mohammad va ale mohammad" in interventional group and phone off in control group. Before and during pray meditation, 30, 60 minutes, 3 and 6 hours after pray meditation pain intensity, blood pressure, heart rate and respiratory rate were measured. No statistically significant improvement in pain score was found before and during pray meditation, 30, 60 minutes after pray meditation (P>0.05). Statistically significant improvement in pain score was found at 3 and 6 hours after pray meditation than control group (1.5 ± 0.3 vs. 3 ± 1.3, P=0.030) and (1.3 ± 0.8 vs. 3 ± 1.1, P=0.003). However, there was no significant difference in the physiological responses (systolic and diastolic blood pressure, respiration, and heart rate) any time between the groups. Religion and spirituality intervention such as pray meditation could be used as one of non-pharmacological pain management techniques for reducing pain after cesarean surgery. Also, Pray meditation provides less postoperative nausea and vomiting (PONV) and more relaxation.