Preoperative Gabapentin for Pain Control: A Randomized, Placebo-controlled Clinical Trial in Patients Undergoing Inguinal Hernioplasty.

PURPOSE: The perioperative use of gabapentin has been suggested to reduce postoperative pain and opioid consumption. However, there is a variation in clinical practice, the type of surgery and the administration time seem to be distinct between the available studies. We assess whether gabapentin administered before surgery reduces postoperative pain in patients who have undergone inguinal hernioplasty. DESIGN: This is a double-blind, randomized, and placebo-controlled trial. METHODS: Seventy-seven patients scheduled for inguinal hernioplasty were randomized in two groups to receive gabapentin (900 mg) or placebo in the perioperative period. The primary outcome was analgesia measured by visual analog scale up to 30 days after surgery. The secondary outcomes such as morphine consumption, nausea, headache, and sedation have been also described. FINDINGS: Patients who received gabapentin had lower postoperative pain scores compared to the control group, P < .001. The postoperative morphine use was significantly lower in the gabapentin (5.3%) versus placebo group (74.4%), P < .001. No significant difference between groups was observed for the occurrence of adverse events. CONCLUSIONS: The perioperative administration of gabapentin was effective in reducing postoperative pain and had an important effect in decreasing morphine use. Together, our data reveal a long-lasting opioid-sparing effect of gabapentin in patients who underwent inguinal hernioplasty.

Torsion of the inferior vena cava: An unprecedented variant of post-pneumonectomy syndrome.

Post-pneumonectomy syndrome (PPS) is a rare complication after pneumonectomy defined by mediastinum shift toward the vacated pleural space with compression of the distal trachea or mainstem bronchi, resulting in dyspnea. This report describes a 32-year-old woman who presents with limiting symptoms of progressive dyspnea and chest pain 2 years after a right pneumonectomy. In computed tomography scan, there was no evidence of airway compression but suggested torsion of the inferior vena cava with preload compromise, confirmed during the surgical mediastinum repositioning using a transesophageal echocardiography-guided approach. This case report presents this unprecedented variant of PPS syndrome, highlighting the diagnostic and peri-operative management challenges.

Anaesthetic management of a patient with Gerbode defect.

Gerbode defect is a rare left ventricle to right atrium shunt that can be acquired or congenital. The incidence of acquired defects has been growing and is caused by previous cardiac surgery, endocarditis, trauma and myocardial infarct. It can be challenging and the anesthesiologist should maintain a suspicion when there is circulatory failure after a cardiac surgery. It can be diagnosed by trans-esophageal echocardiography. In this case we presented the anesthetic management and the successful surgical correction of an acquired ventricular-atrial defect secondary to a previous mitral valve replacement.

Central pontine myelinolysis after liver transplant: A case report and an updated review.

Based on brain magnetic resonance imaging results, the second and third most frequent causes of central pontine myelinolysis (CPM) were liver transplant (LT) and cirrhosis, which together accounted for 13.7% and 12.5% of all diagnoses of CPM. Medical diseases including cirrhosis, LT, malnutrition, and alcoholism are well-known conditions associated with CPM in addition to hyponatremia. The prognosis is poor and depends on early diagnosis and treatment to achieve better outcomes. This is a case report of CPM occurring after a deceased donor LT in a patient presenting many risk factors such as chronic hyponatremia, previous episodes of encephalopathy, and tacrolimus immunosuppression. We briefly discuss the pathophysiology, risk factors, diagnosis, and treatment, highlighting the role and challenges of the anesthesiologist in managing this kind of patient and preventing the syndrome in the context of major surgery.

A Case Report of Cerebral Hypoperfusion During Liver Transplant with a Focus on the Role of Intraoperative Neuromonitoring.

Acute hepatic failure is characterized by rapid deterioration of hepatic function with encephalopathy in a patient without pre-existing liver disease. Bispectral index values had a significant correlation with cerebral perfusion. Transcranial Doppler can assess changes in cerebrovascular function and has the advantages of being noteworthy and widely available. This is a case report of a hepatic encephalopathy occurring during a deceased donor liver transplant in a patient presenting fulminant hepatitis. We briefly discuss some diagnostic methods highlighting the challenges of the anesthesiologist in managing this kind of patient in the context of a major surgery.

Preclinical study in a postoperative pain model to investigate the action of ketamine, lidocaine, and ascorbic acid in reversing fentanyl-induced, non-glutamate-dependent hyperalgesia.

Introduction: Opioid-induced hyperalgesia (OIH) is a paradoxical phenomenon in which exposure to opioids can increase sensitivity to painful stimuli. Currently, several drugs have been used in an attempt to prevent OIH. We design this study to address the effect of preemptive treatment with ketamine, lidocaine, and ascorbic acid in a rat preclinical model of perioperative opioid-induced hyperalgesia. Methods: To reproduce OIH in a model of postoperative pain, rats received successive doses of fentanyl subcutaneously and underwent an incision in the paw. In an attempt to prevent OIH, ketamine, lidocaine, and ascorbic acid were administered before treatment with fentanyl. The von Frey test and the hot-plate test were used to evaluate mechanical allodynia and thermal hyperalgesia, respectively, with a follow-up period from 1 hour up to 7 days after surgery. Spinal cord nerve terminals (synaptosomes) were used to assess glutamate release under our experimental conditions. Results: Consecutive fentanyl injections increased the postoperative pain as indicated by increased thermal hyperalgesia and allodynia 48 hours after incision. Ketamine, lidocaine, and the combination of ketamine + lidocaine were able to prevent thermal hyperalgesia but not mechanical allodynia. Ascorbic acid did not prevent the hyperalgesia induced by fentanyl. We found no correlation between spinal glutamate release and the pharmacological treatments. Conclusion: Fentanyl induced a hyperalgesic effect that last few days in a postoperative model of pain. Hyperalgesic effect was not totally inhibited by ketamine and lidocaine in rats. Increased glutamate release was not the main molecular mechanism of fentanyl-induced hyperalgesia.

Differential diagnosis of intraoperative cardiac arrest after spine surgery in prone position.

Intraoperative cardiac arrest is one of the most feared events by anesthesiologists and surgeons. Although there are many possible causes, three differential diagnoses stand out in the presented scenario: pulmonary embolism, gas embolism, and acute myocardial infarction. A 61-year-old female patient was admitted in the hospital to C2-C5 arthrodesis. Despite no major bleeding during surgery, immediately after supination the patient developed refractory hypotension, a decrease in end tidal CO2, progressive bradycardia that ultimately led to pulseless electrical activity. Resuscitation maneuvers were promptly performed, sustained return of spontaneous circulation was attained after 50 minutes, and the patient was transferred to the ICU. This paper discusses the main causes for an episode of cardiac arrest in the context of cervical arthrodesis, with a markedly prolonged resuscitation time, in which the patient survived.

Anesthetic management in bilateral video-assisted thoracoscopic sympathectomy for refractory ventricular arrhythmias: A case report.

Cardiac Sympathetic Denervation (CSD) has been shown to reduce shocks and subsequent pain of implantable cardiac defibrillator (ICD) in patients with heart diseases and recurrent Ventricular Tachycardia (VT) who did not respond properly to oral therapy and ablation. A 68-year-old man who presented an idiopathic dilated cardiomyopathy with impaired ejection fraction was treated for VT. A bilateral cardiac sympathetic denervation was performed under general anesthesia. Patient was extubated in the operating room and transferred to ICU where he presented hypotension. He was discharged after five days and remained symptom-free without any incident of VT during hospital stay. Currently no definite anesthetic management is available to treat such patients. This report discusses an approach that made heart rate control and safe patient discharge possible.