Retrospective Evaluation of the Effect of Lumbar Sympathetic Blockade on Pain Scores, Fontaine Classification, and Collateral Perfusion Status in Patients with Lower Extremity Peripheral Arterial Disease.

Background and Objectives: The aim of this retrospective study was to evaluate the effect of lumbar sympathetic block (LSB) on pain scores, Fontaine Classification, and collateral perfusion status in patients with lower extremity peripheral artery disease (PAD), in whom revascularization is impossible. Material and Methods: Medical records of 21 patients with PAD who underwent LSB with a combination of local anesthetics, steroids, and patient follow-up forms containing six-month follow-ups between January 2020 and March 2021 were retrospectively reviewed. Numeric Rating Scale (NRS), Pain Detect Questionnaire (PDQ) scores, Fontaine Classification Stages, and collateral perfusion status (collateral diameter and/or development of neovascularization) evaluated by arterial color Doppler Ultrasound (US) from the medical records and follow-up forms of the patients were reviewed. Results: NRS and PDQ scores were significantly lower, and regression of the Fontaine Classification Stages was significantly better after the procedure at the first, third, and sixth month than at the baseline values (p < 0.001). Only four patients (19%) had collaterals before the procedure. An increase in the collateral diameter after LSB was noted in three out of four patients. Before the procedure, 17 patients had no prominent collateral. However, in thirteen of these patients, after LSB, neovascularization was detected during the six-month follow-up period (three patients in the first month, seven patients in the third month, and thirteen patients in the sixth month). The number of patients evolving neovascularization after LSB was found to be statistically significant at the third and sixth months compared to the initial examination (p < 0.001). Conclusions: LSB with the use of local anesthetic and steroids in patients with lower extremity PAD not only led to lower NRS and PDQ scores, but also resulted in regressed Fontaine Classification Stages and better collateral perfusion status.

Can stellate ganglion blockage be an alternative treatment for refractory ventricular arrhythmias: Case series.

INTRODUCTION: Ventricular tachycardia (VT) and ventricular fibrillation (VF) are life-threatening conditions which increase in frequency over the years. Electrical storm (ES) is defined as the occurrence of 3 or more continuous ventricular arrhythmia. The sympathetic nervous system has an important role in Ventricular arrythmias (VA) and is the target of treatment. Studies show that stellate ganglion blockade (SGB) can reduce cardiac sympathetic tone and is an alternative bridge therapy in VAs. PATIENT CONCERNS: Among the patients who were admitted to the hospital with the complaints of general condition disorder and palpitation. DIAGNOSIS: Patients were referred to the Cardiology department and diagnosed VA and ES. Patients who applied to the Cardiology Department with the diagnosis of VA or ES and did not benefit from antiarrhythmic drug therapy were selected and evaluated by a team of 2 anesthesiologists (cardiothoracic and pain specialists) and 2 cardiologists (1 of whom is an electrophysiology specialist). INTERVENTION: In our study, ultrasound (USG) guided left SGB was applied to 10 VA and ES patients with implantable cardiac defibrillator (ICD). The 6-month results of the patients were evaluated retrospectively. For blockage, the solution was prepared by adding 8 mg dexamethasone, 40 mg lidocaine and 10 mg bupivacaine to 10 mL with physiological saline. The success of the procedure was evaluated with the development of Horner syndrome in the left eye. OUTCOMES: Resistant VA developed in 2 of 10 patients who had left SGB due to VF/VT ES and were excluded from the study. One (1) month after the procedure it was seen that there was a statistically significant decrease in the number of shocks in 8 patients in the 6th month controls compared to the pre-procedure. The number of VES in the 1st and 6th months of the patients was also statistically significantly decreased compared to the pre-SSD (P = .01, P = .01, P = .01, respectively). CONCLUSION: Unilateral USG-guided SGB application is an effective and safe method in patients with ES and VA. Long-term results can be satisfactory in successful responders in whom SGB is performed with a combination of local anesthetic and steroid.

The relationship between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients.

OBJECTIVES: The purpose of the study was to evaluate any comorbid psychiatric disorders in patients with chronic pain and to examine the effects of sociodemographic details and the level of somatic sense perception on the severity of these diseases. METHODS: In this study, 51 chronic pain patients were evaluated in a consultation with a psychiatrist. Sociodemographic characteristics of the patients, such as age, gender, education level, and marital status were recorded, and Structured Clinical Interview for DSM-IV results were assessed. The patients' chronic pains were classified as idiopathic or secondary to organic etiology. In addition, the Symptom Checklist-90, Somatosensory Amplification Scale (SSAS), Hamilton Depression Rating Scale, and the Hamilton Anxiety Scale (HAM-A) were used. RESULTS: The incidence of psychiatric disorders in chronic pain patients was found to be 74.5%. Somatoform disorders were the most frequently diagnosed, at 37.3%. The rate of depressive and anxiety disorders was, respectively, 29.4% and 23.5%. Comorbid anxiety scores (p=0.019) and SSAS scores (p=0.046) were significantly higher in chronic pain patients with a somatoform disorder. HAM-A scores were found to be significantly higher in patients with depression (p=0.004). A positive and linear relationship was determined between the SSAS score and depression, anxiety, and the severity of mental symptoms. CONCLUSION: Structured or semi-structured interviews can be performed in pain polyclinics or psychiatric outpatient clinics to determine the level of perception of somatic sensations. This could be beneficial in the treatment of chronic pain and comorbid psychiatric disorders.

Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain: Comparison of monopolar and bipolar modes.

OBJECTIVES: Radiofrequency thermocoagulation (RFT) has been reported to be used safely to treat ischemic lower extremity pain. The objective of the present study was to evaluate efficiency of RFT for treatment of lower extremity ischemic pain and to compare effectiveness of monopolar RFT and bipolar RFT modes. METHODS: Following ethics committee approval, 30 American Society of Anesthesiologists classification I-III patients with ischemic lower extremity pain aged between 18 and 65 years were recruited. Patients were randomly allocated into 2 groups: MRT group (n=15) received monopolar RFT (80°C) for 2 minutes at L2-3 level, and BRT group (n=15) received bipolar RFT (80°C) for 2 minutes at L2-3 level. Systolic and diastolic blood pressure, heart rate, pain score, and supplemental analgesic requirements were recorded at 24 hours after application and at 7, 30, and 90 days. RESULTS: Numerical rating scale values in both groups decreased significantly over time and it was found to be significantly lower in BRT group after first and third months (p<0.05). Supplemental analgesic requirements were similar with no significant difference between the 2 groups at any point of study period (p>0.05). No adverse event or complication related to procedure or treatment was reported. CONCLUSION: In patients with ischemic lower extremity pain, both monopolar and bipolar RFT treatment modalities were found to significantly decrease pain levels. However, bipolar mode led to lower pain scores at 30 and 90 days, and longer duration of analgesia than monopolar mode.

Bipolar Versus Unipolar Intraarticular Pulsed Radiofrequency Thermocoagulation in Chronic Knee Pain Treatment: A Prospective Randomized Trial.

BACKGROUND: Chronic knee pain is a major widespread problem causing significant impairment of daily function. Pulsed radiofrequency has been shown to reduce severe chronic joint pain as a non-pharmacological and less invasive treatment method. OBJECTIVE: We aimed to compare the effectiveness of unipolar and bipolar intraarticular pulsed radiofrequency methods in chronic knee pain control. STUDY DESIGN: Prospective, randomized, double-blind study. SETTING: Pain clinic in Cukurova University Faculty of Medicine. METHODS: One hundred patients, aged 20 - 70 years with grade 2 or 3 knee osteoarthritis were included in this study. Patients were randomly allocated into 2 groups to receive either unipolar (group U, n = 50) or bipolar (group B, n = 50) intraarticular pulsed radiofrequency (IAPRF) with a 45 V voltage, 2 Hz frequency, 42° C temperature, 10 msec pulse width, and 10 minute duration. We recorded visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index LK 3.1WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index LK 3.1) scores of patients at baseline and one, 4, and 12 weeks after the procedure. The primary outcome was the percentage of patients with ≥ 50% reduction in knee pain at 12 weeks after the procedure. RESULTS: There was a significant difference between the groups according to VAS scores at all post-intervention time points. In group B, 84% of patients, and in the group U, 50% of patients achieved at least 50% knee pain relief from the baseline to 3 months. In group B, WOMAC scores were significantly lower than the group U at one and 3 months. LIMITATIONS: Lack of long-term clinical results and supportive laboratory tests. CONCLUSION: Bipolar IAPRF is more advantageous in reducing chronic knee pain and functional recovery compared with unipolar IAPRF. Further studies with longer follow-up times, laboratory-based tests, and different generator settings are required to establish the clinical importance and well-defined mechanism of action of PRF. This study protocol was registered at clinicaltrials.gov (identifier: NCT02141529), on May 15, 2014. Institutional Review Board (IRB) approval date: January 16, 2014, and number: 26/9Key words: Chronic pain, intraarticular, knee joint, knee osteoarthritis, pain management, pulsed radiofrequency treatment, quality of life, recovery of function.

[Effect of ondansetron in lower extremity bone surgery on morphine and tramadol consumption using patient controlled analgesia]. / Alt ekstremite kemik cerrahisinde hasta kontrollü analjezide ondansetronun tramadol ve morfin tüketimine etkisi.

In this study, we aimed to assess the effect of administration of ondansetron on morphine and tramadol consumptions. After approval by the ethics committee, 120 patients with ASA status I or II, who will undergo elective lower extremity surgery, were included in the study. Patients were randomly divided into 4 groups following the anesthesia induction. Group I received tramadol as PCA with an infusion of 0.3 mg/kg following a loading dose of 1.5 mg/kg administered 1 hour before the end of the surgery. Group II received ondansetron 0.1 mg/kg following induction of anesthesia, additionally. Group III received morphine as PCA with an infusion following a loading dose of 0.15 mg/kg administered 30 minutes before the end of surgery. Group IV received ondansetron 0.1 mg/kg following induction of anesthesia, additionally. Pain scores(VAS), nausea, vomitting and sedation scores, analgesic consumptions and adverse effects were recorded at 5th, 15th, 30th, 45th minutes and 4th, 8th, 12th and 24th hours postoperatively. Postoperative VAS, nausea, vomitting and sedation scores were similar among the groups. The analgesic consumption was found significantly higher at 4th, 8th, 12th and 24th hours in group II. No statistically significant difference was found in analgesic consumption between group III and IV at all times. We concluded that, ondansetron, when administered as nausea prophylaxis in patients receiving tramadol and morphine as PCA, did not effect morphine consumption whereas did increased tramadol consumption.

[Comparison of ropivacaine, ropivacaine plus tramadol and ropivacaine plus morphine in patients undergoing minor hand surgery]. / Minör el cerrahisinde rejyonal intravenöz anestezide ropivakain, ropivakain-tramadol ve ropivakain-morfinin karsilastirilmasi.

In our study we aimed to compare the effects of ropivacaine alone, ropivacaine plus tramadol HCl, and ropivacaine plus morphine HCl used as intravenous regional anesthesia (IVRA), on duration to the initiation of analgesia, total analgesia time, analgesic requirement, sedation levels and hemodynamic parameters. 53 patients undergoing minor hand surgery were included into the study. Patients were randomly divided into three groups to receive 40 ml of ropivacaine 0.2 % (Group R, n=18), ropivacaine 0.2 % plus 1 mg/kg tramadol HCl (Group RT, n=18), and ropivacaine 0.2 % plus 0.1 mg/kg morphine HCl (Group RM, n=17) as IVRA. Following the injection, the durations for the initiation of analgesia were recorded. Levels of sedation, analgesia (VAS) and hemodynamic parameters were recorded in 5 minute intervals throughout first 35 minutes intraoperatively and at 1, 5, 10, 15, 20, 30, 45 and 60th minutes postoperatively. Patients were asked about the initiation of pain and requirements of analgesic at the first postoperative day. The duration to the initiation of analgesia was similar between the groups. Total analgesia time was found to be 304.0 +/- 317.6 min in Group R, 327.0 +/- 316.5 min in Group RT, and 635.9 +/- 492.3 min in Group RM. The difference between Group R and RM was statistically significant (p<0.05). Analgesic requirements were similar between the groups (p>0.05). Mild local anesthetic toxicity was observed in Group RM in two patients. We conclude that, when used as IVRA, ropivacaine alone or with tramadol or morphine produced similar analgesia and surgery conditions, and ropivacaine plus morphine had more adverse effects besides its longer duration of analgesia.

[Effect of tramadol on regeneration after experimental sciatic nerve injury]. / Deneysel siyatik sinir hasarinin rejenerasyonunda tramadolün etkisi.

Abnormal impulses in peripheral nerves play a critical role in neuropathic pain syndromes. The voltage-gated Na+ channels that underlie the action potential are main targets for clinically useful drugs in the pain therapy. Systemic tramadol has been shown to have clinical efficacy against some forms of neuropathic pain. Therefore, we investigated the mechanisms of action of tramadol by an in vitro model by sucrose-gap technique. Tramadol produced concentration-dependent and frequency-dependent decrements in CAP amplitude. Also, injured nerves were more sensitive to tramadol. Tramadol decreased the amplitude of the delayed depolarization and the hyperpolarizing afterpotentials. In conclusion, blocking potencies of small concentration tramadol on the delayed depolarization and hyperpolarizing afterpotential in regeneration period may be contributed for understanding of the action mechanisms of tramadol on neuropathic pain therapy.

Safe and effective sedation and analgesia for bone marrow aspiration procedures in children with alfentanil, remifentanil and combinations with midazolam.

BACKGROUND: Invasive procedures such as bone marrow aspiration in children may be painful and cause anxiety. We investigated the efficacy and safety of remifentanil (R) alfentanil (A), remifentanil-midazolam (RM), and alfentanil-midazolam (AM) combinations in providing analgesia and sedation for bone marrow aspiration. METHODS: Eighty children undergoing a diagnostic bone marrow aspiration whose ages ranged from 5-16 years (mean 9.20 +/- 3.00 years) were enrolled in this study. The patients were randomly assigned to one of 4 treatment groups. Vital signs, sedation and pain scores, somatic responses (sweating and tears) were recorded before, during bone marrow aspiration and after 5 and 15 min of the procedure. RESULTS: There were no statistical differences between sedation and the CHEOPS scores of the four groups during and after the procedures. The VAS scores were significantly higher for group A compared with groups R and RM during the procedure (P < 0.008). There were no differences between the VAS scores in group AM compared with groups R and RM (P > 0.008). There were also no statistical differences among the VAS scores of four groups after the procedure (P > 0.008). All patients had adequate sedation and analgesia. None of the patients in the study had deep sedation, hypotension, bradycardia, hypoxemia, or respiratory depression. CONCLUSIONS: Remifentanil, alfentanil, remifentanil-midazolam, and alfentanil-midazolam combinations are effective in children and can be used safely in bone marrow aspiration which is a brief but painful procedure performed in the pediatric patient group.

The comparison of caudal ketamine, alfentanil and ketamine plus alfentanil administration for postoperative analgesia in children.

BACKGROUND: Our aim was to compare the effect of single dose caudal ketamine, alfentanil or a mixture of both drugs in the treatment of pain after hypospadias repair surgery in children. METHODS: The group comprised 109 boys, ASA I-II, aged 1-9 years, who were undergoing hypospadias repair surgery as day cases. The children were randomly divided into three groups for postoperative analgesia: group 1, only alfentanil (20 microg x kg(-10) was given caudally; group 2, ketamine (0.5 mg x kg(-1)) alone; and group 3, alfentanil (20 microg x kg(-1))-ketamine (0.5 mg x kg(-1)) was given caudally. The analgesic effect of caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using a five-point sedation score. The first analgesic requirement time and the number of supplementary analgesics required by each child in a 24-h period were also recorded. RESULTS: No statistical differences were found in demographic characteristics, haemodynamic and respiratory parameters, objective pain scores, postoperative sedation scores and duration of surgery among the groups. The median time to first analgesia was significantly shorter in group 1 than in groups 2 and 3 (P=0.009, P=0.001). Significantly more patients in group 1 required additional postoperative analgesia (paracetamol 15 mg x kg(-1)) compared with groups 2 and 3 (P < 0.001). CONCLUSIONS: Caudal administration of ketamine 0.5 mg.kg-1 with or without alfentanil in children produced satisfactory postoperative analgesia without respiratory depression or other side-effects.