Oral 30% glucose provides sufficient sedation in newborns during MRI.

PURPOSE: Newborns are often sedated during MRI but sedation itself creates adverse events and management is more challenging in this environment. Oral glucose/sucrose administration has been studied in newborns during painful procedures; however, its effectiveness in keeping newborns sleepy and motionlessness during painless procedures has not been demonstrated. The objective of this study was to describe effectiveness of oral 30% glucose administration by comparing with intravenous midazolam sedation for newborns during MRI. METHODS: One hundred twelve ASA II-III newborns who required care in the ICU and were scheduled for MRI with sedation were included. Group I received 30% glucose solution orally with 0.5-1 ml increments up to 2 ml/3 kg doses and group II received intravenous 0.1 mg/kg midazolam with 0.05 mg/kg repetition. The procedure was considered satisfactory when MRI images were not disturbed by patient movement after oral glucose or intravenous midazolam administration. The efficiency of the techniques, additional dose and rescue sedation requirements, blood glucose levels following oral 30% glucose suckling and presence of adverse events were recorded. RESULTS: Demographic data was similar between groups. The efficiency of the procedures were similar between groups (78.9%, in group I and 66.1%, in group II). The blood glucose levels were within normal range in group I whereas transient desaturation and apnea occurred in 8 neonates in group II (p = 0.006). CONCLUSION: Oral 30% glucose administration for newborns during MRI is as effective as standard sedation protocol with midazolam. Thereby, we recommend and support the integration of this safe and reliable technique into routine practice for newborns during MRI.

Management of neuropathic pain with methylprednisolone at the site of nerve injury.

OBJECTIVE: Peripheral nerve blocks with methylprednisolone may provide effective pain therapy by decreasing ectopic neuronal discharge and the release of local inflammatory mediators at the site of nerve injury. In this study, we aimed to compare the efficacy of lidocaine alone with a combination of depo-methylprednisolone plus lidocaine in the management of neuropathic pain due to peripheral nerve damage. DESIGN: Randomized, double-blind comparator trial. SETTING: Group control (N = 44) received 0.5% lidocaine and group methylprednisolone (N = 44) received 80 mg depo-methylprednisolone + 0.5% lidocaine proximal to the site of nerve injury with a total amount of 10-20 mL solution according to the type of peripheral nerve block with nerve stimulator. OUTCOME MEASURES: Demographic data, preblock numerical rating scales (NRSs), the Leeds assessment of neuropathic symptoms and signs (LANSS(0) ) score, accompanying symptoms, and analgesic requirements were recorded. Postblock NRS scores were noted following peripheral nerve block and after 3 months. LANSS(1) , accompanying symptoms, and analgesic requirements were also reevaluated 3 months after the injection. RESULTS: Demographic data, preblock NRS (8 ± 1.5 and 8.1 ± 1.2, respectively), postblock NRS (2.1 ± 1.2 and 2.4 ± 1.4, respectively), LANSS(0) (18.4 ± 2.2 and 18.2 ± 2.1, respectively), and accompanying symptoms were comparable between groups. Scores for the methylprednisolone group were significantly improved at 3-month postblock for NRS (2 ± 1.4 vs 5.2 ± 1.7) and LANSS(1) scores (4.14 ± 2.7 vs 14.1 ± 2.8), accompanying symptoms, and analgesic requirements (P < 0.0001). CONCLUSIONS: Our results suggest that peripheral nerve block with 80 mg depo-methylprednisolone plus 0.5% lidocaine provides effective management in the treatment of neuropathic pain due to peripheral nerve damage.

IV paracetamol effect on propofol-ketamine consumption in paediatric patients undergoing ESWL.

PURPOSE: Electroshock wave lithotripsy (ESWL) is a painful procedure performed with sedoanalgesia in paediatric patients. The propofol-ketamine combination may be the preferable anaesthesia for this procedure, and propofol-ketamine consumption may be decreased with the administration of intravenous (IV) paracetamol. In this study we investigated the effect of IV paracetamol administration on propofol-ketamine consumption, recovery time and frequency of adverse events in paediatric patients undergoing ESWL. METHODS: Sixty children, ranging in age from 1 to 10 years and with American Society of Anesthesiologists Physical Status 1-2, were included in this prospective, randomized, double-blinded study. Thirty minutes prior to the procedure children randomly assigned to Group I received IV 15 mg/kg paracetamol, and those randomly assigned to Group II received 1.5 mL/kg IV saline infusion 30 min. The propofol-ketamine combination was prepared by mixing 25 mg propofol and 25 mg ketamine in a total 10 mL solution in the same syringe. After the administration of 0.1 mg/kg midazolam and 10 µg/kg atropine to both groups and during the procedure, the propofol-ketamine combination was administered at 0.5 mg/kg doses to achieve a Wisconsin sedation score of 1 or 2. Oxygen saturation and heart rate were recorded at 5-min intervals. Propofol-ketamine consumption, recovery times and adverse events were also recorded. RESULTS: Demographic data were similar between groups. Propofol-ketamine consumption (Group I, 25.2 ± 17.7 mg; Group II, 35.4 ± 20.1 mg; p = 0.04) and recovery times (Group I, 19.4 ± 7.9 min; Group II, 29.6 ± 11.4 min; p < 0.0001) were significantly different between groups. Saturation, heart rate and adverse events were similar in both groups. CONCLUSION: Our data suggest that the administration of IV paracetamol decreases propofol-ketamine consumption for adequate sedation during ESWL procedures in paediatric patients and shortens recovery time.

Transsacral S2-S4 nerve block for vaginal pain due to pudendal neuralgia.

Pudendal neuralgia is a type of neuropathic pain experienced predominantly while sitting, and causes a substantial decrease in quality of life in affected patients. Pudendal nerve block is a diagnostic and therapeutic option for pudendal neuralgia. Transsacral block at S2 through S4 results in pudendal nerve block, which is an option for successful relief of pain due to pudendal nerve injury. Herein is reported blockade of S2 through S4 using lidocaine and methylprednisolone for successful treatment of pudendal neuralgia in 2 patients with severe chronic vaginal pain. The patients, aged 44 and 58 years, respectively, were referred from the Gynecology Department to the pain clinic because of burning, stabbing, electric shock-like, unilateral pain localized to the left portion of the vagina and extending to the perineum. Their initial pain scores were 9 and 10, respectively, on a numeric rating scale. Both patients refused pudendal nerve block using classical techniques. Therefore, diagnostic transsacral S2-S4 nerve block was performed using lidocaine 1%, and was repeated using lidocaine 1% and methylprednisolone 80 mg after confirming block efficiency as demonstrated by an immediate decrease in pain scores. After 1 month, pain scores were 1 and 0, respectively, and both patients were free of pain at 6-month follow up. It is suggested that blockade of S2 through S4 using lidocaine and methylprednisolone is an effective treatment option in patients with chronic pudendal neuralgia when traditional pudendal nerve block is not applicable.

Thoracic epidural anesthesia and analgesia during the perioperative period of thoracic surgery: levobupivacaine versus bupivacaine.

OBJECTIVES: To compare the effects of thoracic epidural anesthesia with levobupivacaine or bupivacaine on block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery. DESIGN: A prospective, randomized, and double-blind study. SETTING: A university hospital. PARTICIPANTS: Fifty patients undergoing thoracic surgery. INTERVENTIONS: Patients received thoracic epidural catheterization either with levobupivacaine or bupivacaine. A bolus of 0.1 mL/kg of 0.25% levobupivacaine or 0.25% bupivacaine was administered, and infusion of the same drug with 0.25% concentration was started at 0.1 mL/kg/h. General anesthesia was induced after assessing the sensory block and maintained with 0.3% to 0.8% isoflurane and 50% O(2) in air. Epidural patient-controlled analgesia with the same agent was started at the end of the operation for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Sensory block features such as onset time and spread were assessed for the next 20 minutes after the bolus dose. Heart rate and systolic, diastolic, and mean arterial blood pressures were recorded intraoperatively and postoperatively. Pain at rest and activity was evaluated by the visual analog scale (VAS) for 48 hours after the operation. All patients were comparable with respect to the demographic data. Onset time of the block and the number of blocked dermatomes and hemodynamic parameters were similar in both groups. All VAS assessments were comparable between groups except VAS at the 36th hour postoperative, which was higher in the levobupivacaine group (p = 0.039). CONCLUSIONS: Thoracic epidural anesthesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery.

The effect of paracetamol on postoperative nausea and vomiting during the first 24 h after strabismus surgery: a prospective, randomised, double-blind study.

CONTEXT: Strabismus surgery is one of the most common ophthalmic surgical procedures in children and is associated with significant postoperative nausea and vomiting (PONV). OBJECTIVE: We evaluated the effect of intravenous paracetamol on PONV in children after strabismus surgery. DESIGN: Prospective, placebo-controlled, randomised double-blind study. SETTING: University hospital. PATIENTS: Ninety children, between 2 and 14 years scheduled for strabismus surgery, were recruited. Eighty-six completed the study. INTERVENTIONS: After induction of anaesthesia, intravenous dexamethasone 0.1 mg kg was administered to all. The patients were enrolled to receive either intravenous physiological saline (group S) or paracetamol 15 mg kg (group P). MAIN OUTCOME MEASURE: Incidence of PONV in the first 24 h postoperatively. RESULTS: General and clinical characteristics of the children were similar in both groups. PONV during the first 24 h was significantly higher in group S in comparison with group P (group S vs. group P, 33 vs. 14.6%, respectively, P = 0.038 for nausea; 24.4 vs. 7.3%, respectively, P = 0.030 for vomiting). The number of analgesic administrations during the first 24 h was higher in group S compared with group P (1.31 ±â€Š0.85 and 0.73 ±â€Š0.6, respectively, P = 0.001). The repeat number of postoperative analgesic administrations was significantly different between groups during the first 24 h (P = 0.005), but during 24-48 h was not significant. CONCLUSION: Intraoperative administration of intravenous paracetamol decreases the incidence of PONV during the first 24 h in children after strabismus surgery.

Intrathecal catheterization after unintentional dural puncture during orthopedic surgery.

PURPOSE: We investigated whether inserting an intrathecal catheter and leaving it in place for 24 h after an unintentional dural puncture in orthopedic patients reduced the incidence of post-dural puncture headache (PDPH). METHODS: The study consisted of 427 patients in whom a total of 21 unintentional dural punctures had occurred during orthopedic surgery performed between 2002 and 2006. Seven patients (phase I; evaluated retrospectively) each underwent placement of an epidural catheter at another level after dural puncture during the period January 2002 to February 2004. Fourteen patients (phase II; evaluated prospectively) received an epidural catheter through the dural tear after an unintentional dural puncture during the period February 2004-March 2006 RESULTS: In phase I, 5 of the 7 patients experienced PDPH, and one required an epidural blood patch. In phase II, only one of the 14 patients complained of PDPH, which resolved after 48 h of medical therapy. No patient experienced paresthesia, neurologic or hemorrhagic complication, or infection. CONCLUSION: Inserting an epidural catheter through the dural tear following an unintentional dural puncture and leaving it in place for 24 h significantly reduces the incidence of PDPH.

The impact of two arterial catheters, different in diameter and length, on postcannulation radial artery diameter, blood flow, and occlusion in atherosclerotic patients.

PURPOSE: Arterial cannulation is a common intervention in anesthesia practice. However, the success rates and complications of radial arterial cannulation with 20-G or smaller catheters in patients with atherosclerosis have been underevaluated. The aim of this prospective randomized study was to compare the efficacy of and complications with 20- and 22-G catheters for radial arterial cannulation in atherosclerotic patients. METHODS: Thirty patients with atherosclerosis, American Society of Anesthesiologists (ASA) III-IV, undergoing general anesthesia were enrolled in the study. Radial artery cannulation was performed in group 20G (n = 15) with a 20-gauge (20 x 1.1 x 33 mm; flow, 61 ml.min(-1)) catheter and in group 22G (n = 15) with a 22-gauge (22 x 0.9 x 25 mm; flow, 36 ml.min(-1)) catheter. Radial artery systolic blood flow (SBF) and radial artery diameter (RAD) were assessed by a Doppler ultrasound probe before cannulation and 24 h after decannulation for vascular complications. The number of puncture attempts, arterial blood gas samples, and manual flushes; total heparinized solution consumption; duration of cannulation; decannulated radial arterial systolic blood flow; postcannulation RAD; and vascular complications such as occlusion, hematoma, pseudoaneurysm, bleeding, and thrombosis were noted. The Mann Whitney U-test, chi(2) test, and one-sample t-test were used. Values are expressed as medians and quartiles and P < 0.05 was considered as significant. RESULTS: The number of puncture attempts was greater in group 20G (range, 1 to 4) than in group 22G (range, 1 to 2; P = 0.02). In group 20G patients, postoperative RAD was larger than preoperative RAD (P = 0.02) and postoperative SBF was lower than preoperative SBF (P = 0.03). In group 22G patients postoperative SBF was higher than preoperative SBF (P = 0.03), while there was no significant difference between preoperative and postoperative RAD. The occlusion rate of atherosclerotic radial arteries was 6% with the 22-gauge catheter and 26% with the 20-gauge catheter (P = 0.02). CONCLUSION: A 22-gauge catheter for radial arterial cannulation in patients with atherosclerosis provides unchanged postcannulated radial artery diameter, decreases postcannulation complications, and improves the first-attempt success rate.

Management of isolated infraorbital neuralgia by ultrasound-guided infraorbital nerve block with combination of steroid and local anesthetic.

Patients with isolated peripheral branch neuralgia of trigeminal nerve usually receive traditional treatment such as medical therapy and interventional procedures targeting the entire trigeminal nerve or related ganglions. However, if the intractable pain is limited to a certain branch, the patient may also benefit from a peripheral and nerve-targeted interventional approach. Here, we report the management of a patient with isolated infraorbital neuralgia by ultrasound-guided infraorbital nerve block with steroid and local anesthetic combination. 48years-old male patient diagnosed with trigeminal neuralgia was resistant to medical therapy for 3years. The pain site was isolated to the area of the right nasal wing, right lateral incisor, the upper right canine and the first premolar teeth. His pain was an electric shock-like, throbbing and stabbing with a pain score of 8-9 according to numeric rating scale (NRS) and 18 according to the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (LANSS). Following a diagnostic ultrasound-guided infraorbital nerve block with 1% lidocaine, the block was repeated twice with 15mg lidocaine and 1.5mg dexamethasone in a total volume of 1.5mL in a month. The patient's NRS and LANSS scores decreased to 2 and 8, for approximately 21months until this report was written. We suggest that ultrasound-guided infraorbital nerve block with dexamethasone and lidocaine combination may present as an initial interventional treatment option in patients with isolated infraorbital neuralgia.

The efficacy of intra-articular lidocaine administration in chronic knee pain due to osteoarthritis: A randomized, double-blind, controlled study.

BACKGROUND: Intra-articular injections for the treatment of knee pain due to osteoarthritis are performed when conservative therapies have failed. The intra-articular injection of lidocaine may be an effective treatment modality due to its neuronal membrane-stabilizing effect and long-lasting anti-inflammatory action. In this study, we compared the efficacy of intra-articular 0.5% lidocaine versus saline injection on pain, stiffness and physical function in patients with osteoarthritis. METHODS: Patients with osteoarthritis were randomly allocated to two groups. Group I (n=26) received 7mL 0.5% lidocaine and group II (n=26) received 7mL saline into the painful knee for a series of three injections spaced by 1 week intervals under ultrasound guidance. Knee pain was measured with a numeric rating score (NRS) at baseline and 3 months after the 3rd injection. WOMAC scales, including pain (WOMAC-P), stiffness (WOMAC-S) and physical function (WOMAC-F), were assessed and recorded at baseline, 30minutes after the 1st injection, immediately prior to the 2nd and 3rd injections and 3 months after the 3rd injection. RESULTS: Demographic data were comparable between groups. The NRS after 3 months was significantly lower in group I (P=0.001). The WOMAC-P, immediately prior to the 3rd injection and 3 months afterwards, was significantly lower in group I (P=0.006, P=0.001, respectively). The WOMAC-S was improved prior to the 3rd injection and sustained until 3 months in group I (P=0.035, P=0.004, respectively). The WOMAC-F was improved after the 1st injection and sustained until 3 months in group I (P=0.002, P<0.0001 and P<0.0001, respectively). CONCLUSIONS: Intra-articular 0.5% lidocaine injection under ultrasound guidance has a potential role in the management of chronic knee pain due to osteoarthritis for a 3-month period.

Postoperative analgesic efficacy of fascia iliaca block versus periarticular injection for total knee arthroplasty.

STUDY OBJECTIVE: This study evaluated the postoperative analgesic efficacies of fascia iliaca block and periarticular drug injection techniques after TKA (total knee arthroplasty) surgeries. DESIGN: Prospective, randomized clinical trial. SETTING: University Teaching and Research Center. PATIENTS: Seventy-one American Society of Anesthesiologists (ASA) I-III patients between 48 and 70 years of age who underwent total knee arthroplasty were randomized. INTERVENTIONS: Tenoxicam (20 mg) was administered intramuscularly to both groups of patients 30 minutes before surgery. Patients were randomized into two groups to receive fascia iliaca block before the induction of anesthesia (Group FI) or periarticular drug injection during the surgery (Group PI). All surgeries were performed under general anesthesia using standard techniques. Postoperative analgesia was provided with patient-controlled intravenous morphine. MEASUREMENTS: Total morphine consumption was the primary outcome measure and was recorded postoperatively at 1, 2, 6, 12 and 24 hours. Pain levels at rest and on movement (knee flexion) were evaluated using the Visual Analogue Scale (VAS) and recorded at the same time points. Patients' demographics, rescue analgesic demands, side effects, hemodynamics, and satisfaction scores were also recorded. MAIN RESULTS: The groups had similar VAS scores both at rest and on movement (P>.05). However, the amount of cumulative morphine and use at each follow-up period was higher in Group PI (P<.0001). The groups did not differ significantly in rescue analgesic use or side effects, such as nausea/vomiting, hemodynamic variables, and patient satisfaction scores (P>.05). CONCLUSIONS: Fascia iliaca block may be used as an alternative method to periarticular injection, and it effectively reduces the amount of morphine used to relieve post-TKA pain.

[Modified van-Lint technique for the management of postherpetic neuralgia: case report]. / Post-herpetik nevralji tedavisinde modifiye van-Lint blokaji: Olgu sunumu.

Acute herpes zoster (AHZ) causes postherpetic neuralgia (PHN) in 48-75% of patients. Nerve blocks performed in the acute phase of HZ may treat the pain and prevent PHN development. Here, we present pain relief with modified van-Lint block in two cases with AHZ involving vesicles on the traces of the supraorbital and supratrochlear nerves. Two female patients, 72 and 66 years old, with AHZ involving vesicles on the traces of the supraorbital and supratrochlear nerves starting from the right periocular region to the scalp presented with symptoms such as hypoesthesia, dizziness, burning, throbbing, and severe pain. Their initial visual analogue scale (VAS) scores for pain were 9 and 10, respectively. Supraorbital and supratrochlear nerve blockade with modified van-Lint technique was planned, as the classical nerve block sites were covered with active vesicles. Following the nerve blocks, VAS scores of both patients decreased to 1 immediately. Vesicles were faded and scabbed, symptoms such as hypoesthesia, burning and throbbing had recovered, dizziness was relieved, and VAS scores were 4 and 5, respectively, after one week. VAS scores were 1 and 2, respectively, after the second injection, and all symptoms were resolved, and no additional analgesic was required during a three-month follow-up. Modified van-Lint block with 5 mL 1% lidocaine may provide successful pain relief in AHZ involving vesicles on the traces of the supraorbital and supratrochlear nerves.

A treatment option for post-injection sciatic neuropathy: transsacral block with methylprednisolone.

BACKGROUND: Accidental intraneural injection induced nerve injury is an iatrogenic tragedy and intramuscular injection (IM) is the most common injury mechanism affecting the sciatic nerve. The most frequent presentation of sciatic nerve injury includes radicular pain and paresthesia with almost immediate onset of variable motor and sensory deficit. OBJECTIVES: Intraneural injection is a common injury mechanism of the sciatic nerve and generates neuropathic pain with inflammatory neuritis. Steroids inhibit the production of inflammatory mediators and reduce ectopic discharges on damaged neural membranes. The results of transsacral steroid injection on neuropathic pain in 5 patients with accidental sciatic nerve injury due to intraneural injection were presented in this report. DESIGN: Report of 5 cases. DESCRIPTION OF CASES: Five patients, 32, 34, 45, 54 and 70 years old respectively, complaining of severe neuropathic pain, paresthesia and progressive weakness of the lower extremity with difficulty in walking secondary to gluteal injection were admitted to the clinic. The symptoms were resistant to drug therapies. Electromyography disclosed axonal damage of the sciatic nerve. The initial examination of the patients revealed a Numeric Rating Scale (NRS) of 10, 10, 9, 9, and 10 respectively. RESULTS: Diagnostic block was performed through the unilateral S1-S2-S3 sacral foramina with 22-G spinal needle by 5 mL 1% lidocaine into each foramen. NRS scores decreased to 1, 2, 2, 2 and 1, respectively. One week later, the patients were administered 80 mg methylprednisolone with 1% lidocaine in 15 mL solution shared equally in each foramen. The patients were checked one month after therapeutic block and a full recovery was achieved in all patients. CONCLUSION: The neuropathic pain due to accidental intraneural injection of the sciatic nerve would be an acceptable indication for transsacral nerve block with corticosteroids in the treatment of sciatic neuropathic pain symptoms.