The First Awake Craniotomy for Seizure Focus Resection in Iran 2016.

Patient with refractory seizure may undergo awake craniotomy when the area to be resected is immediately adjacent to eloquent cortex. An awake craniotomy in a 30-year-old man was conducted using a scalp block, dexmedetomidine, and remifentanil infusion without any airway device throughout the procedure. Dexmedetomidine administered at a loading dose of 1 µg/kg and maintenance dose of 0.2-0.7 µg/kg/h. Remifentanil dose was 0.02 µg/kg/min. The patient remained comfortable and hemodynamically stable throughout the procedure. Cortical electrical stimulation revealed motor cortex overlapped with seizure focus. So that surgical procedure was limited to subpial resection of the epileptic focus. Dexmedetomidine with concurrent scalp block appears to be an useful sedation for awake craniotomy when sophisticated neurological test is required.

Comparison the Effects of Intraoperative Labetalol and Lidocaine on Postoperative Blood Pressure and Heart Rate in Brain Surgeries.

BACKGROUND: Long-term anesthesia applied in some operations, especially in neurosurgical operations leads to unwanted complications. This study aimed to compare the effect of intraoperative labetalol and lidocaine injection on the rate of changes in postoperative blood pressure and heart beat in patients undergoing brain operation. MATERIALS AND METHODS: This is a simple double-blind randomized clinical trial study conducted in Al-Zahra and Kashani Hospitals on 90 patients' candidate for craniotomy operation with the age range of 18-65 years, Glasgow Coma Scale (GCS) ≥13 before anesthesia, physical class of American Society of Anesthesiologists I, II, insensitivity to labetalol who were divided into two groups of 45 individuals in the random allocation method. To start anesthesia, fentanil 1.5 mg per 1 kg of body weight, midazolam 5 mg, propofol 2 mg/kg and then, atracurium 0.15 mg/kg and lidocaine 1.5 mg/kg were used. The rate of patients' bucking and blood pressure were checked at GCS time after operation and in patients' recovery in terms of 0, 5, 10, 20 and 30 min after arrival in the recovery room and 1 h later. RESULTS: There was no significant difference in terms of hemodynamic parameters during the period of operation and recovery and at the time of extubation and during the study, no case of bradicardia, hypotension, tachycardia or hypertension was observed in the patients of both groups. CONCLUSION: Using labetalol in craniotomy surgery is helpful for two main reasons that are the proper control of intraoperative and postoperative blood pressure and prevention of postoperative reactions, especially cough and if there is no contraindication for using it, it is recommended.

Comparing the Effect of Labetalol versus Morphine on Controlling Blood Pressure and Pulse Rate during Emergence from Anesthesia after Craniotomy.

BACKGROUND: Emergence from anesthesia is associated with sympathetic stimulation, increase in pulse and blood pressure. There are different methods, but the most appropriate method should be selected regarding the differences in nationalities. This study aimed to compare the efficacy of morphine and labetalol in controlling blood pressure and pulse during emergence from anesthesia in brain tumors craniotomy. MATERIALS AND METHODS: This study was conducted at Al-Zahra Hospital of Isfahan - Iran on 60 patients suffering from brain tumor candidated for craniotomy and randomly classified into two groups of 30. One group received labetalol with dose of 10 mg over 10 min from 45 min before finishing dressing and then 0.75 mg/min until 35 min later; another group received morphine in bolus dose of 0.1 mg/kg during 2-3 min. Blood pressure and pulse were measured every 10 min over 40 min. After operation, they were measured every 5 min over 15 min. RESULTS: The morphine group had higher systolic (133.3 ± 18.8) and diastolic blood pressure (87.1 ± 13.6) (P = 0.021 and 0.028, respectively) at extubation and during 45 min before dressing, the diastolic blood pressure was significantly higher in compares with labetalol (75.3 ± 10.5) (P < 0.05). And extubation time was significantly shorter in labetalol group (7.7 ± 0.84) (P < 0.001). Pulse had no significant difference in both groups. In labetalol group, blood pressure and pulse fluctuations were more stable. CONCLUSION: Administration of labetalol 45 min before finishing dressing can significantly control blood pressure during emergence from anesthesia and also shorten the time of extubation during emergence in patients undergoing craniotomy.

Preemptive peritonsillar infiltration with bupivacaine in combination with tramadol improves pediatric post-tonsillectomy pain better than using bupivacaine or tramadol alone: A randomized, placebo-controlled, double blind clinical trial.

BACKGROUND: Post-tonsillectomy pain is one of the most common problems after anesthesia, therefore use of a good anesthesia technique with minimum side effect is an important aim. This study was performed to compare the efficacy of peritonsillar infiltration of bupivacaine, tramadol and combination of bupivacaine-tramadol in post-tonsillectomy pain. MATERIALS AND METHODS: In a double blind trial 120 ASA I and II children condidated for tonsillectomy were randomized into four groups: Peritonsillar infiltration with bupivacaine 1 mg/kg in Group B, tramadol 2 mg/kg in Group T, combination of bupivacaine-tramadol in Group BT and saline in Group C was done. RESULTS: Until 60 minutes in the recovery room, control of pain in the first three groups were better than Group C (P < 0.05) and in the third group it was better than others. Four hours after surgery, control of pain was better in the second and third groups in comparison to Groups B and Group C (P <0.05) and was better in the third group in comparison to the second group. Then, 24 hours after that, only in the group III the control of pain was effective (P < 0.05). CONCLUSIONS: In this study we showed that peritonsillar infiltration with combination of bupivacain-tramadol provided less post surgery pain compared with infiltration of bupivacaine and tramadol alone in adenotonsillectomy of children.

Comparison of five methods in predicting difficult laryngoscopy: Neck circumference, neck circumference to thyromental distance ratio, the ratio of height to thyromental distance, upper lip bite test and Mallampati test.

BACKGROUND: Preoperative airway assessment tests have been presented to help in anticipating a difficult airway. We conducted this study to compare five methods in prediction of difficult laryngoscopy: Neck circumference (NC), NC to thyromental distance ratio (NC/TMD), the ratio of height to thyromental distance (RHTMD), upper lip bite test (ULBT) and Mallampati test (MMT). These five methods are the most commonly used ones and have different powers for it. It was not clear which of these methods predicts difficult laryngoscopy better. MATERIALS AND METHODS: Six hundred consecutive patients participated in this study. NC, NC/TMD and RHTMD were measured, and ULBT and MMT were performed and recorded. The laryngoscopy view was graded according to Cormack and Lehane's scale (CLS) and difficult laryngoscopy was defined as CLS grades 3 and 4. Accuracy of tests in predicting difficult laryngoscopy was assessed using the area under a receiver-operating characteristic curve. RESULTS: The area under the curve in ULBT and RHTMD were significantly larger than that in TMD, NC and MMT. No statistically significant differences were noted between TMD, NC and MMT (all P > 0.05) (ULBT = RHTMD > NC/TMD > TMD = NC = MMT). RHTMD (>22.7 cm) exhibited the highest sensitivity (sensitivity = 64.77, 95% confidence interval [CI]: 53.9-74.7) and the most specific test was ULBT (specificity = 99.41%, 95% CI: 98.3-99.9). CONCLUSION: RHTMD and ULBT as simple preoperative bedside tests have a higher level of accuracy compared to NC/TMD, TMD, NC, MMT in predicting a difficult airway.

Magnesium sulfate versus Lidocaine pretreatment for prevention of pain on etomidate injection: A randomized, double-blinded placebo controlled trial.

OBJECTIVE: Etomidate is an imidazole derivative and formulated in 35% propylene glycol. When given without a rapid lidocaine injection, etomidate is associated with pain after injection. Magnesium (Mg) is a calcium channel blocker and influences the N-methyl-D-aspartate receptor ion channel. The aim of the study is to evaluate the efficiency of preemptive injection of magnesium sulfate and lidocaine on pain alleviation on etomidate intravenous injection. METHODS: In a randomized, double-blinded trial study, 135 adult patients scheduled for elective outpatient or inpatient surgery were divided into three groups. Group M received 620 mg magnesium sulfate, Group L received 3 ml lidocaine 1% and Group S received normal saline, all in a volume of 5 mL followed by a maximal dose of 0.3 mg/kg of 1% etomidate. Pain was assessed on a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain and 3 = severe pain at the time of pretreatment and etomidate injection. FINDINGS: About 60% of patients in the control group had pain during etomidate injection as compared to 22.2% and 40% in the lidocaine and magnesium sulfate groups, respectively. There was difference in induction pain score between three treatment groups, significantly (P = 0.01) and observed differences in pain scores between "normal saline and lidocaine group" (P < 0.001) and "normal saline and magnesium sulfate groups" were statistically meaningful (P = 0.044). CONCLUSION: Intravenous magnesium sulfate and lidocaine injection are comparably effective in reducing etomidate-induced pain.

Intrathecal Meperidine versus intrathecal Fentanyl for prevention of shivering in lower limb orthopedic surgeries under spinal anesthesia: A randomized double-blind placebo-controlled trial.

OBJECTIVE: Shivering is an unpleasant sensation for patients who undergoing spinal anesthesia. This randomized double-blind clinical trial study was designed to compare the effect of intrathecal fentanyl with intrathecal meperidine for prevention of shivering in lower limb orthopedic surgeries under spinal anesthesia. METHODS: Ninety patients were randomly recruited to receive either 3 ml of 0.5% hyperbaric bupivacaine plus 20 µg of fentanyl (Group F), or 3 ml of 0.5% hyperbaric bupivacaine plus 0.2 mg/kg of meperidine (Group M), or 3 ml of 0.5% hyperbaric bupivacaine plus normal saline (Group S). The incidence and intensity of shivering were compared in three groups. Data were analyzed by analysis of variances, Mann-Whitney U-test followed by Chi-square test. FINDINGS: There were not statistically differences in complications and side-effects between three groups. Total incidence of shivering was similar between Groups F and M (16.7% vs. 13.3% respectively, P = 0.72) whereas it was significantly different to Group S (43.3%) (P = 0.025 for Group F vs. S, and P = 0.011 for Group M vs. S). Also the intensity of shivering between Groups F and M was similar (P = 0.66), while it was significantly less in these groups compared to Group S (P = 0.013 and P = 0.004, respectively). CONCLUSION: Addition of fentanyl 20 µg or meperidine 0.2 mg/kg to 0.5% bupivacaine intrathecally significantly decreased the incidence of shivering in lower limb orthopedic surgeries. There was no significant difference between two drugs with this respect.

Intravenous dexamethasone versus ketamine gargle versus intravenous dexamethasone combined with ketamine gargle for evaluation of post-operative sore throat and hoarseness: A randomized, placebo-controlled, double blind clinical trial.

BACKGROUND: Sore throat and hoarseness are the most frequent subjective complaints after tracheal intubation for general anesthesia. We conducted a prospective, randomized, double-blind, placebo controlled study to evaluate the efficacy of intravenous (IV) dexamethasone plus ketamine gargle for reducing the incidence and severity of post-operative sore throat (POST) and hoarseness. MATERIALS AND METHODS: 140 patients (aged 16-65 year) scheduled for elective surgery were enrolled. Patients were randomly allocated into four groups of 35 subjects each: Group K, gargled 40 mg ketamine in 30 ml saline; Group D, were infused 0.2 mg/kg IV dexamethasone; Group KD, gargled 40 mg ketamine in 30 ml saline plus 0.2 mg/kg IV dexamethasone; Group P (placebo) that received saline (gargle and IV). POST was graded at 0, 2, 4, 8, 16 and 24 h after operation on a four-point scale (0-3). RESULTS: The incidence and severity of POST were significantly lower in Group KD, compared with the other groups at all times after tracheal extubation for up to 24 h (P < 0.05). Also the incidence and severity of hoarseness were significantly lower in each Groups of KD and K and D compared with group placebo (P < 0.05). CONCLUSION: The prophylactic use of 0.2 mg/kg of IV dexamethasone plus ketamine gargle significantly reduced the incidence and severity of POST compared with using each of these drugs alone or using placebo.

Prophylactic effects of intrathecal Meperidine and intravenous Ondansetron on shivering in patients undergoing lower extremity orthopedic surgery under spinal anesthesia.

OBJECTIVE: Intraoperative hypothermia is a common problem with anesthesia. Spinal anesthesia, the same as general anesthesia, affects the process of temperature regulation. The aim of this study was to compare the prophylactic effect of intravenous (IV) ondansetron with intrathecal (IT) meperidine on prevention of shivering during spinal anesthesia in patients underwent orthopedic surgery of the lower limb. METHODS: In this study, 120 patients with American Society of Anesthesiologists physical status I to II, between the ages 16 and 65 were randomized into three groups. Group O and Group M were given IV ondansetron 8 mg and IT meperidine 0.2 mg/kg, before spinal anesthesia, respectively. Group C received IV saline 0.9%. The core and ambient temperatures, the incidence and intensity of shivering, blood pressure, heart rate, and maximum level of sensory block were recorded. FINDINGS: Shivering was observed in 15%, 2.5%, and 37.5% of patients in Groups O, M, and C, respectively. There was a significant difference between Group O and M compared to Group C (P = 0.023 for Group O vs. Group C, P < 0.001 for Group M vs. Group C, P = 0.049 for Group M vs. Group O). Shivering incidence and intensity in Group M was significantly lower than Group O (P = 0.049 and P = 0.047, respectively). Twenty-two patients required additional IV meperidine among which 15 patients were from Group C (37.5%), six patients from Group O (15%) and one patient from Group M (2.5%). CONCLUSION: We concluded that IT meperidine and IV ondansetron comparably can decrease intensity and incidence of shivering compared to control group as well as decreasing the requirement to additional doses of meperidine for shivering the control without any hemodynamic side effect.

Comparison of the effects of two different formulas of fluids in craniotomy patients.

BACKGROUND: Intraoperative fluid management of the patients who had undergone neurosurgery presents special challenges for the anesthesiologist. In this study, we aimed to compare the effects of two fluid combinations (half-normal + bicarbonate with saline + Ringer's lactate) on brain relaxation, and acid, base, and hemodynamic balance in patients undergoing elective craniotomy surgery. MATERIALS AND METHODS: This randomized double-blind controlled clinical trial study was done on 50 patients, of age 20-60 years, undergoing craniotomy in Alzahra Hospital in 2012. They were divided in two groups of 25 patients each. In the control group, after the patients received hypertonic saline, normal saline serum and Ringer's lactate was administered, and in the half-normal study group, 80 ml of sodium bicarbonate for every liter of it was added. Arterial blood gas (ABG) was taken before the last suture. Brain relaxation before dura opening was registered. RESULTS: There was no significant difference in heart rate changes (P = 0.054). No significant difference was observed in the mean arterial pressure between the two groups (P = 0.99). Changes in pH, HCO3, and BE were not significantly different (P = 0.99) between the two groups. Urine output in half-normal saline group was significantly higher than in normal saline group. The mean bleeding volume was higher in normal saline group, but was not significantly different (P = 0.54). The mean volume of injected blood was higher in half-normal group with a significant difference (P = 0.54). The injected blood volume mean in half-normal group was higher with no significant difference (P = 0.55). The mean of brain relaxation was not different (P = 0.5). CONCLUSION: These two fluids did not show any significant differences in the studied variables in this research.

Awake craniotomy for tumor resection.

Surgical treatment of brain tumors, especially those located in the eloquent areas such as anterior temporal, frontal lobes, language, memory areas, and near the motor cortex causes high risk of eloquent impairment. Awake craniotomy displays major rule for maximum resection of the tumor with minimum functional impairment of the Central Nervous System. These case reports discuss the use of awake craniotomy during the brain surgery in Alzahra Hospital, Isfahan, Iran. A 56-year-old woman with left-sided body hypoesthesia since last 3 months and a 25-year-old with severe headache of 1 month duration were operated under craniotomy for brain tumors resection. An awake craniotomy was planned to allow maximum tumor intraoperative testing for resection and neurologic morbidity avoidance. The method of anesthesia should offer sufficient analgesia, hemodynamic stability, sedation, respiratory function, and also awake and cooperative patient for different neurological test. Airway management is the most important part of anesthesia during awake craniotomy. Tumor surgery with awake craniotomy is a safe technique that allows maximal resection of lesions in close relationship to eloquent cortex and has a low risk of neurological deficit.