A Comparative Study of the Effect of Low-Dose Epinephrine and Ketamine on Rapid-Sequence Endotracheal Intubation by the Priming Dose Method of Cisatracurium in Patients under General Anesthesia.

Background: Low-dose ephedrine and ketamine may accelerate the onset time of action of neuromuscular blocking agents. We studied the effect of ephedrine and ketamine and cisatracurium priming on endotracheal intubation conditions and the onset time of action of cisatracurium. Materials and Methods: The study was a double-blind clinical trial performed on American Society of Anesthesiologists (ASA) class 1 and 2 patients, who were candidates for general anesthesia. In total, 120 patients were entered into the study and were divided into 4 groups, E, K, E + K, and N. The first group was given 70 mcg/kg ephedrine (E group), the second group was given 0.5 ml/kg ketamine (K group), the third group was given the same amount of ketamine plus ephedrine (E + K group), and the fourth group was given the same volume of normal saline (control group); a single dose of 0.1 mg/kg cisatracurium was given, and intubating conditions were evaluated at 60 seconds after cisatracurium administration. Results: The mean Cooper score based on the response to laryngoscopy, the position of the vocal cords, and the movement of the diaphragm of patients in the control group with a mean of 2.53 ± 1.07 was significantly lower than in the three groups of E, K, and E + K with the means of 4.47. 1.17, 4.53 ± 1.14, and 7.63 ± 1.42, respectively (P value < 0.001). In the (E + K) group, it was significantly higher than in the two other drugs alone (P value < 0.001). The two groups of E and K alone were not significantly different from each other (P value = 0.997). The means of hemodynamic parameters were not significantly different in any of the groups (P value > 0.05). Conclusion: According to the results of the present study, the use of low-dose ephedrine and ketamine alone can improve intubation conditions. In addition, the combined use of these drugs not only had any Positive effect on patients' hemodynamic parameters but also greatly improved intubation conditions.

Assessment of Neck Characteristics for Laryngeal Mask Airway Size Selection in Patients Who Underwent an Elective Ocular Surgery; A Cross-Sectional Study.

Objective: To investigate the neck features for laryngeal mask airway (LMA) size selection. Methods: This cross-sectional study was conducted on 160 patients referred for elective surgeries to Feiz Hospital affiliated with Isfahan University of Medical Sciences, Isfahan, Iran (April 2016 to September 2018). Patients underwent ventilation using LMA whose size was determined through a weighted-based approach. All of the patients' neck characteristics including circumference, thyromental distance, and opening mouth were measured. Ventilation factors were recorded including numbers of attempts for successful LMA insertion, quality of ventilation, and sealing. Results: Neck circumference and thyromental distance were significantly different with the size of LMA (p<0.0001 and p=0.005, respectively), but not mouth opening (p=0.21). Neck circumference, thyromental distance, and mouth opening were not significantly different with the times of insertion attempts (p>0.05 for all comparisons). However, the thyromental distance was significantly different with the quality ventilation status (p<0.0001). The total assessment of insertion attempts, ventilation efficacy and sealing was significantly different with the neck circumference (p<0.001), but thyromental distance did not show a significant difference (p>0.05). Conclusion: Findings demonstrated that neck circumference might be considered as an appropriate indicator for the selection of LMA size but neither the thyromental distance nor mouth opening. Further studies with a larger sample size are strongly recommended.

A COMPARATIVE STUDY OF THE ANALGESIC EFFECT OF INTRAVENOUS PETHIDINE VS. KETOROLAC AFTER INGUINAL HERNIA SURGERY IN CHILDREN UNDER GENERAL ANESTHESIA.

INTRODUCTION: Postoperative pain due to tissue damage caused during surgery not only causes discomfort for the patients, but can also result in prolonged hospitalization, increased morbidity and respiratory disorders, and readmission to the hospital. For postoperative pain control, numerous methods and medications have been suggested, such as non-steroidal anti-inflammatory drugs (NSAIDs) and narcotics. Pethidine, as a narcotic analgesic, and ketorolac, as an NSAID, are widely used for pain control. Thus, in this study, the effects of these two drugs were studied and compared in terms of pain control after inguinal hernia surgery in children of 1-12 years of age. MATERIALS AND METHODS: Sixty-six children undergoing inguinal herniorrhaphy were selected and randomly divided into 2 groups. The first group received 0.5 mg/kg ketorolac and the second group received 1 mg/kg pethidine during extubation. Postoperative pain (using Wong Baker pain scale) and complications were measured until 24 hours after surgery. RESULTS: Mean and standard deviations of postoperative pain 1 hour after surgery in the pethidin and ketorolac groups were 5.06 ± 1.41 and 3.88 ± 0.93, respectively. The scale was significantly lower in the ketorolac group (P < 0.001). Postoperative pain intensity 2 hours after surgery in these two groups was 4.48 ± 1.52 and 3.55 ± 1.15, respectively, and the difference between the two groups was significant (P = 0.006). The variation in postoperative pain intensity in the ketorolac group was statistically lower than the pethidin group (P = 0.020). CONCLUSION.

Comparative evaluation of adding different opiates (morphine, meperidine, buprenorphine, or fentanyl) to lidocaine in duration and quality of axillary brachial plexus block.

BACKGROUND: There is no agreement about the effect of adding opioids to local anesthetics in peripheral nerve blocks. The aim of this study was to investigate the effect of adding different opioids with equipotent doses of lidocaine in axillary brachial plexus block using ultrasonography and nerve locator guidance. MATERIALS AND METHODS: In a prospective, randomized, double-blind clinical trial study, 72 adult patients aged 18-65 years old scheduled for orthopedic surgery of the forearm and hand with axillary brachial plexus block were selected and randomly allocated to four groups. Meperidine (pethidine), buprenorphine, morphine, and fentanyl with equipotent doses were added in 40cc of 1% lidocaine in P, B, M, and F groups, respectively. The onset and duration of sensory and motor blocks, severity of patients' pain, duration of analgesia, hemodynamic and respiratory parameters, and adverse events (such as nausea and pruritus) during perioperative period were recorded. RESULTS: The onset time for the sensory block was similar in the four groups. The onset time for the motor block was significantly faster in morphine and pethidine groups (P = 0.006). The duration of sensory and motor blocks was not statistically different among the four groups. The quality of motor blockade was complete in 100% of patients receiving pethidine or morphine and 77.8% of patients receiving buprenorphine or fentanyl (P = 0.021). CONCLUSION: In the upper extremity surgeries performed under axillary brachial plexus block addition of morphine or pethidine to lidocaine may be superior to other opioids (i.e. fentanyl and buprenorphine) due to better quality and quantity of motor blockade and faster onset of the block.

COMPARISON OF PRE-EMPTIVE EFFECT OF MELOXICAM AND CELECOXCIB ON POST-OPERATIVE ANALGESIA: A DOUBLE-BLIND, RANDOMIZED CLINICAL TRIAL.

INTRODUCTION: Pre-emptive analgesia may reduce pain, accelerate recovery and shorten the duration of hospitalization. The present study aims to compare the preemptive analgesic effects of meloxicam and celecoxib in patients undergoing lower limb surgery. METHOD: In this double blind randomized clinical trial, 70 patients, undergoing lower extremity surgery, entered in the study; thirty five patients were randomly allocated to either group using random allocation software. Meloxicam (15 mg) was administered orally to one group two hours before the surgical onset. The other group was treated with oral celecoxib (400 mg) two hours before the operation. Pain severity was compared between the two groups. RESULTS: Upon admission to Recovery Room, the mean pain severity was not significantly different between the two groups. At one and two hours following surgery the mean pain severity was significantly higher in celecoxib group. However, 6 hours following surgery mean pain severity was higher with meloxicam administration. Pain severity was not significantly different in the two groups, 12 and 24 hours following surgery. CONCLUSION: The analgesic effect of celecoxib seems to cover longer duration than meloxicam; but, meloxicam appears to be a stronger analgesic in shorter time interval.

Evaluation of in vivo effects of Oxytocin on coagulation of parturient during cesarean delivery by thromboelastography.

OBJECTIVE: Oxytocin routinely used as an uterotonic drug in cesarean delivery. Clothing problems, adverse effects on fibrinogen and bleeding were presented as side effects of oxytocin. In in vivo investigation, modest hypercoagulable state was suggested as a side effect for infusion of oxytocin in parturients. In this study, effects of two different infusion rates of oxytocin on coagulation of parturient were evaluated during cesarean delivery. METHODS: In a randomized double-blinded clinical trial, 84 healthy parturient in two equal groups took oxytocin infusion with the rate of 15 IU/h (Group A) or 30 IU/h (Group B), after the umbilical cord clamping. Coagulation status measured 30 min after beginning of infusion by thromboelastography. Data were analyzed by χ(2), paired sample test and ANOVA considering as significant at P < 0.05. FINDINGS: The mean (standard deviation) of variables in Groups A and B were 2.4024 (0.86) and 2.0429 (0.68) for K (kinetics of clot development), 55.4429 (11.30) and 60.7595 (10.41) for α (speed of clot strengthening) and 59.779 (19.15) and 70.61 (11.30) for maximum amplitude (maximum clot strength), respectively. The P values for these variables were 0.036, 0.028 and <0.001, respectively; these changes are consistent with increasing coagulability. Other measures did not have significant differences. CONCLUSION: This in vivo investigation clarified that increasing infusion rate of oxytocin to 30 IU/h can augment coagulability in term parturients.

Effect of preemptive and preventive acetaminophen on postoperative pain score: a randomized, double-blind trial of patients undergoing lower extremity surgery.

STUDY OBJECTIVE: To compare postoperative pain scores and rescue analgesic use in patients who received acetaminophen preoperatively or during skin closure versus those who received a placebo. DESIGN: Randomized, double-blind clinical trial. SETTING: University-based, tertiary-care hospital. PATIENTS: 75 adult, ASA physical status 1 and 2 undergoing lower extremity orthopedic surgery. INTERVENTIONS: Patients were randomized to three groups. The control group received 100 mL of intravenous (IV) normal saline as a placebo. The preventive acetaminophen group received 100 mL of IV normal saline plus 15 mg/kg of acetaminophen prior to skin closure. The preemptive acetaminophen group received 15 mg/kg of IV acetaminophen combined with 100 mL of normal saline half an hour preoperatively. MEASUREMENTS: Pain was scored with the verbal rating scale and assessed 5 minutes before spinal anesthesia, and 6, 12, 18, and 24 hours after surgery. Total rescue meperidine consumption by each patient during the first 24 hours after surgery was also recorded. MAIN RESULTS: Pain scores were lower in both preemptive and preventive acetaminophen groups at 6 hours after surgery than in the placebo group (P < 0.001). There were no differences in pain scores after 6 hours between the preemptive and preventive groups. Total analgesic consumption 24 hours after surgery was lowest in the preemptive acetaminophen group (P < 0.01). Average time to initial analgesic requirement was slightly longer in the preemptive and preventive acetaminophen groups than the control group (P < 0.01). CONCLUSION: In patients undergoing lower extremity surgery with spinal anesthesia, both preventive and preemptive acetaminophen may enhance analgesia and decrease postoperative analgesic consumption.

The comparison of spinal anesthesia with general anesthesia on the postoperative pain scores and analgesic requirements after elective lower abdominal surgery: A randomized, double-blinded study.

BACKGROUND: The aim of this study was to compare the postoperative pain scores and morphine requirements between spinal anesthesia (SA) with hyperbaric bupivacaine 0.5% and general anesthesia (GA) with 1 Minimal alveolar concentration minimal alveolar concentration (MAC) of isoflurane in 50% N2O and O2 after elective lower abdominal surgery. MATERIALS AND METHODS: In this randomized clinical trial, 68 patients with American Society of Anesthesiologists (ASA) I or II undergoing lower abdominal surgery were randomly assigned to have elective lower abdominal surgery under SA (n = 34) or GA (n = 34). The SA group received 3 cc of 0.5% hyperbaric bupivacaine (15 mg), at L3-L4 interspace intrathecally and also 2 mic/kg fentanyl and 0.15 mg/kg morphine intravenously for intraoperative analgesia. In the GA group, induction of anesthesia was carried out with Na thiopental 6 mg/kg body weight, fentanyl 2 mic/kg body weight, morphine 0.15 mg/kg, and atracurium 0.6 mg/kg body weight, and then, trachea was intubated. The primary outcome was postoperative pain scores at rest and under stress on a visual analog scale and the secondary outcome was morphine requirement by the patients. Outcome measures were recorded at 2, 4, 6, 12, and 24 h postoperatively. The duration of postanesthesia care unit (PACU) and hospital stay were recorded. Intraoperative parameters, postoperative pain scores, complications, recovery time, and the duration of hospital stay at follow up were compared between the two groups. RESULTS: Patients in SA group had significantly lower scores of a postoperative pain at rest (3.4 ± 1.6 and 4.1 ± 1.2 at 2 and 4 h postoperatively vs. 5.2 ± 1.5 and 5.8 ± 0.9 in the GA group with P < 0.05), but there were no significant differences between both groups for scores of postoperative pain at 6, 12, and 24 h. The amount of morphine requirement in 6 h postoperatively was significantly lower in the SA group (10.2 ± 4.3 mg vs. 15.6 ± 5.6 mg in the GA group with P < 0.05), but there were not significant differences between the two groups after 6 h postoperatively. The duration of PACU stay was shorter for the GA group than the SA group (75 ± 6 vs. 126 ± 12 min, P < 0.001), but there was no significant differences between the duration of hospital stay between the two groups (1.8 ± 0.6 vs. 2.1 ± 0.8 days). CONCLUSION: Although in patients undergoing elective lower abdominal surgery with SA may have lower pain scores and also lower morphine requirement in the first 6 h postoperatively, but after that there were no significant differences between SA and GA regarding postoperative pain scores and analgesic requirements and so more attention should be given to their postoperation pain relief.

The comparison of intraincisional injection tramadol, pethidine and bupivacaine on postcesarean section pain relief under spinal anesthesia.

BACKGROUND: Bupivacaine, tramadol, and pethidine has local anesthetic effect. The aim of this study was to compare effect of subcutaneous (SC) infiltration of tramadol, pethidine, and bupivacaine on postoperative pain relief after cesarean delivery. MATERIALS AND METHODS: 120 patient, scheduled for elective cesarean section under spinal anesthesia, were randomly allocated to 1 of the 4 groups according to the drugs used for postoperative analgesia: Group P (Pethidine) 50 mg ,Group T (Tramadol) 40 mg, Group B (Bupivacaine 0.25%) 0.7 mg/kg, and Group C (control) 20CC normal saline injection in incision site of surgery. Pain intensity (VAS = visual analogous scale) at rest and on coughing and opioid consumption were assessed on arrival in the recovery room, and then 15, 30, 60 minutes and 2, 6, 12, 24 hours after that. RESULTS: VAS scores were significantly lower in groups T and P compared with groups B and C except for 24 hours (VAS rest) and 6 hours (VAS on coughing) postoperatively (P < 0.05). The number of patients requiring morphine were significantly different between the groups (105 doses vs. 87, 56, 46, doses for group C, B, T and P, respectively, P < 0.05) in all the times, except for 2 and 6 hours postoperatively. CONCLUSIONS: The administration of subcutaneous pethidine or tramadol after cesarean section improves analgesia and has a significant morphine-sparing effect compared with bupivacaine and control groups.

The survey of nurse's knowledge and attitude toward cancer pain management: Application of Health Belief Model.

BACKGROUND: Effective cancer pain management requires accurate knowledge, attitudes, and assessment skills. The purpose of this study was to obtain information about the knowledge and attitudes of nurses concerning cancer pain management with the use Health Belief Model (HBM) as conceptual framework. MATERIALS AND METHODS: The study was a descriptive survey and included 98 randomly selected nurses from Alzahra hospital, Isfahan, Iran. A self-administered questionnaire which was designed on the basis of HBM was used to collect the data. Knowledge, attitudes, and HBM constructs regarding cancer pain were the main research variables. The obtained data were analyzed by SPSS (version11.5) using descriptive statistics, independent t-test, and Pearson correlation at the significant level of α=0.05. RESULTS: Ninety-eight nurses aged 38.7 ± 7.04 years were studied in this survey. From the 10 pain knowledge questions assessed, the mean number of correctly answered question was 61.2 (SD=16.5), with a range of 30-100. There was a direct correlation between knowledge and attitude of nurses with HBM constructs except for perceived barriers and perceived threat. Among the HBM constructs, the highest score was related to self-efficacy with mean score of 87.2 (SD=16.4). CONCLUSIONS: The findings support the concern of inadequate knowledge and attitudes in relation to cancer pain management. We believe that basic and continuing education programs may improve the knowledge level of nursing about pain management.

Bispectral index response to cricoid pressure during induction of general anesthesia.

BACKGROUND: Because the effects of cricoid pressure (CP) on BIS values have not been evaluated, this prospective study was designed to assess the BIS values after application of CP in adult patients during the routine induction of general anesthesia. METHODS: We randomly allocated 70 patients (ASA-I) aged 18-64 years, listed for elective surgery into two groups of cricoid (CP) and non-cricoid (nCP). In the cricoid group, bimanual cricoid pressure was performed after the induction of anesthesia and in the nCP group, simple placement of hands without exerting pressure was performed. Arterial blood pressure, heart rate and BIS were measured and recorded immediately before and after application of cricoid pressure, before laryngoscopy and intubation and then every one minute after intubation until 4 minutes. The data were compared between and within groups using the mixed-design analysis of variance. RESULTS: One minute after application of cricoid pressure and before laryngoscopy, BIS showed significantly higher value compared with the nCP group. Furthermore, one min after intubation, BIS values and arterial blood pressure in-creased significantly in both groups compared with the baseline values, but the increase in BIS value was more signifi-cant in CP group than nCP group. Moreover, BIS values increased significantly 2 minutes after intubation in CP group compared with nCP group. CONCLUSIONS: It was concluded that the application of CP in combination with laryngoscopy and intubation increases the BIS values, which show the inadequacy of anesthesia and hypnosis during the routine induction of anesthesia.

Transvesical blockade of the obturator nerve to prevent adductor contraction in transurethral bladder surgery.

PURPOSE: To evaluate the efficacy of transvesical obturator nerve block (ONB) in the prevention of obturator nerve reflex and leg jerking during transurethral resection of bladder tumors (TURBT). PATIENTS AND METHODS: A total of 60 patients were studied, in whom the transurethral resection of tumors on the posterolateral bladder wall were performed under spinal anesthesia (SA). The patients were randomly divided into two groups. In the first group, we performed transvesical ONB and SA together, while the second group received only SA. The patients underwent TURBT using monopolar cautery. Incidence of leg jerking was registered and compared in these two groups. We used a nerve stimulator to detect the obturator nerve next to the lateral bladder wall. The obturator nerve was identified by its response to nerve stimulation. Then, 10 mL of 1% lidocaine was slowly injected through the working channel of a cystoscope. RESULTS: In the intervention group, 34 ONBs (4 bilateral and 26 unilateral) were tried. We could not detect the obturator nerve by nerve stimulation in six patients, and lidocaine injection was carried out blindly in these cases. One patient in the intervention group experienced adductor contraction. Among 30 patients in the control group, 5 patients had leg jerking, and in 2 patients, the procedure ended incompletely because of muscle spasm. Comparing these two groups, transvesical ONB effectively decreased leg jerking during TURBT (16.5% vs 3%; P < 0.05). CONCLUSION: Local blockade of the obturator nerve during cystoscopy is an effective method to avoid its stimulation in TURBT. It can be performed easily, and we did not experience any serious complication.

Effect of intravenous midazolam premedication on postoperative nausea and vomiting after cholecystectomy.

BACKGROUND: Several drugs and techniques have been used to reduce the incidence of postoperative nausea and vomiting (PONV). However PONV continues to be a common postoperative complication. Midazolam premedication in pediatric patients has been reported to reduce the incidence of PONV. In the present study the effect of intravenous midazolam premedication on the incidence and severity of PONV was investigated in a sample of adult patients undergoing anesthesia for cholecystectomy. METHODS: Eighty-two adult patients undergoing general anesthesia for cholecystectomy were randomly divided into two groups to receive either midazolam 75 microg/kg or a same volume of normal saline intravenously fifteen minutes prior to induction of anesthesia. Incidence and severity of PONV together with the total amount of administered metoclopramide during the first postoperative day were compared between two groups. RESULTS: Severity of nausea was significantly lightened in midazolam group during the first six hours after recovery period compared with placebo group (3.7 +/- 1.6 of a ten point visual analog scale vs. 4.9 +/- 2.2 in placebo group; P < 0.05). Mean number of vomiting episodes was significantly lower in midazolam group (0.4 +/- 0.7 vs. 1.1 +/- 1.4 in placebo group; P < 0.05). Midazolam group received a significantly less amount of metoclopramide during the first postoperative day (2.1 +/- 3.7 mg vs. 5.3 +/- 6.8 mg in placebo group; P < 0.05). CONCLUSIONS: The results of this study suggest the effectiveness of prophylactic intravenous midazolam premedication to reduce the incidence and severity of postoperative nausea and vomiting. Possible mechanisms for this effect of midazolam may be GABA receptor antagonism, inhibition of dopamine release, and anxiolytic effects.