The effect of erector spinae plane block on the use of anesthetic medications in lumbar spine surgery.

OBJECTIVES: To reduce the drug side effects and facilitate the emergence from anesthesia after complex spine surgery, various methods have been proposed. One of these methods is ESPB, which has been less studied. Hence, we conducted this study to evaluate the effectiveness of ESPB on the use of anesthetic drugs in lumbar spine surgery. METHODS: In this study, 70 patients undergoing lumbar spine fusion surgery were studied. Patients were randomly divided into two groups: the case group (n=35), in which bilateral ESPB was done, and the control group (n=35). After standard anesthesia protocols, anesthesia was maintained with isoflurane in both groups. Intraoperative isoflurane and perioperative opioid consumption were recorded. Statistical analysis was performed using SPSS software version 21. RESULTS: Intraoperative use of fentanyl in the case group was significantly lower than the control group (14.29±21.5 vs. 65.96±73.33 µg, p<0.001). Furthermore, isoflurane consumption in the intervention group compared to the controls was significantly lower (20.71±5.02 versus 28.83±8.68 mL, p<0.001). Moreover, the emergence time was significantly shorter in the case group than in the control group (8.49±4.30 minutes versus 15.00±4.94, p<0.001). In the post-anesthesia care unit 1 h after surgery, the pain scores in the case group were significantly lower than the controls (p<0.001). CONCLUSION: ESPB under ultrasound guidance is an effective method of regional anesthesia/analgesia for lumbar spine surgery (fusion) by decreasing the consumption of anesthetics during and following the surgery.

Presentation of Two Simple Methods to Confirm Proper Tracheal Intubation: Palm Pressure, Plastic Bag Inflation, and Bag Pulsation.

Background: The correct placement of the endotracheal tube is a cornerstone of safe anesthesia. Different methods, such as auscultation, capnography, and ultrasound, have their own limitations regarding the confirmation of endotracheal intubation, reinforcing the idea that a single technique is not foolproof. This study proposes a new technique in this regard. Materials and Methods: A total of 600 patients were enrolled in this study, and tracheal intubation was checked with palm pressure and disposable plastic glove inflation and pulsation. Results: The data were analyzed using the t-test and Mann-Whitney U test that indicate 94% and 94.8% sensitivity for palm pressure and bag pulsation, respectively, and a 100% positive predictive value for both tests. Conclusion: Palm pressure and bag pulsation are accurate, inexpensive, and reliable techniques to confirm proper tracheal intubation.

Evaluation of ultrasound guided erector spinae plane block efficacy on post operative pain in lumbar spine surgery: a randomized clinical trial.

OBJECTIVES: Patients suffer notable levels of pain after lumbar spine surgery. The primary objective of this randomized clinical trial is to investigate the efficacy of erector spinae plane block (ESPB) on 24-h post-operative pain score of patients undergoing lumbar spine surgery. Cumulative opioid consumption and intraoperative bleeding were assessed as well. METHODS: Adult patient candidates for elective lumbar spine surgery were randomly assigned to case (ESPB) and control (no ESPB) groups. The block was performed under ultrasound guidance in prone position after induction of general anesthesia. Both groups received the same anesthesia medication and technique. Post-operative pain score, number of patients requiring rescue analgesia (meperidine), total amount of post-operative rescue analgesic demand in the first 24 h, and intraoperative bleeding were recorded. To compare pain score variable in time span, the ANOVA repeated measure test was used. All the statistical tests were two tailed and p<0.05 considered as statistically significant. RESULTS: In all time intervals, pain score in case group was significantly lower than control group. In case group, eight patients demanded rescue analgesic (40%) which was significantly lower than that in control group (15 patients [75%]) (p=0.025). Total amount of meperidine consumption was 57.50±45.95 in control group and 22.50±32.34 in case group (p=0.01) which was higher in control group and statistically significant. CONCLUSION: ESPB reduces post-operative pain score and opioid consumption, while it does not affect intraoperative bleeding in lumbar spine surgery.

Loose Tooth, a Way to Save It: A Case Report.

A loose tooth is a great concern for anaesthesiologists either as a potential foreign body or a bleeding source. A 48-year-old male patient scheduled to undergo a lumbar discectomy had a loose maxillary incisor; he got his tooth fixed by using a thermoplastic external nasal splint. Different approaches such as modification in laryngoscopy or removal of loose teeth have been proposed, but fixing and keeping it in place is not a usual practice which was successfully applied for our patient. Loose incisors could be fixed and protected by using a thermoplastic nasal splint as a mouth guard.

Assessment of Ratio of Height to Rhinion-Mentum Distance as a Predictive Tool for Difficult Tracheal Intubation.

Background: Difficult Intubation (DI) is a constant concern for anesthesiologists and being able to predict it will improve patient safety. Different tests have been presented in anesthesiology practice to increase the accuracy of the DI prediction. Since there is no single sensitive and specific test, most of the practitioners use a combination of them. Here we report a new and novel index of ratio of height to rhinion-mentum distance (RHRMD) to improve the prediction. Materials and Methods: Four hundred adult patients' candidate for elective surgery were enrolled into the study. Initially, patients' data such as weight, height and rhinion-mentum distance (RMD) were recorded by the first anesthesiologist. After anesthesia induction, the second anesthesiologist performed laryngoscopy and recorded the Cormack-Lehane (CL) score. CL score III or higher was considered as DI. Finally, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for RHRMD was calculated. Results: DI was reported in 7.75% of patients. RHRMD is related with CL grade: as the former increased, the latter decreased. RHRMD with cut-off point 25.4 has 90.6% sensitivity, 29.9% specificity, 10.1% PPV and 97.3% NPV in predicting DI. Conclusion: RHRMD with 90.6% sensitivity and 97.3% NPV could be a valuable tool for prediction of DI.

Fanconi Anaemia, What Anaesthesiologists Should Consider about.

Fanconi anaemia (FA) is a rare autosomal recessive inherited disease, which consists of bone marrow failure, skeletal deformities and multi organ nvolvement. Here, we report an emergency surgery on a FA patient with mucormycosis infection of paranasal sinuses. Since there are a few reports about FA, there is no general consensus on anaesthetic considerations so we deal with recommendations that are based on the pathology of FA. Possible difficult air way is the main concern, and low oxygen concentration and avoidance of nitrous oxide are among recommendations.

Hard and Granny Tie, Nasogastric Tube Knotted in Nasopharynx: A Case Report.

Nasogastric tubes are being used in clinical anaesthesia settings on a daily basis. Although rare, knotting could occur during insertion or removal. Here, we report a knotted nasogastric tube which stocked in patient's nasopharynx that was removed by using a pediatric bougie. Clinicians must be aware of potential knotting of nasogastric tube. Pediatric bougie could be utile if knotted tube gets stocked in nasopharynx.

Pulmonary Thromboembolism Following Spine Surgery: Clinical Suspicion is the Key.

Pulmonary thromboembolism following spine surgery, although rare, could end into devastating outcome. Gold standard for it diagnosis is pulmonary CT angiography but in operating theatre, clinical suspicion is the key to diagnose. Here we report a case of pulmonary embolism with classic clinical findings which approved using pulmonary CT angiography and echocardiography.

Tracheal Intubation Using Nelaton Catheter: A Simple Device, an Airway Rescue Option.

Although anticipated, difficult airway could turn into a catastrophe for health care providers, where planned strategies and equipment become useless. We report a challenging airway management process due to narrowed upper airway by the application of a Nelaton catheter as a rescue device.

Pitfalls in Ventilation Devices.

Adequate ventilation is the greatest concern of all the anaesthesiologists. Any disturbance in the ventilation process could result in serious hazards: hypoxemia or barotrauma. Deficient devices are one of many causes of such derangements. Some of the typical complications of airway/ventilation tools are described extensively in textbooks, but many other uncommon events can still occur. We described two interesting cases of device-related ventilation inadequacy, hoping that acquaintance with such jeopardizes would be helpful in emergency situations for other colleagues.

Leprosy, Ancient Disease and Modern Anaesthetic Considerations.

Leprosy is as old as mankind. Although rare, it could be seen in some parts of the world. Therefore, anaesthesiologists have to be familiar with its consequences and considerations that could pose as a challenge. Here, we report a case of leprosy that was referred to our hospital for debridement of his infected foot.

Effect of Intrapleural Meperidine on Post-Operative Pain after Open Cholecystectomy.

BACKGROUND: Post-operative pain after open cholecystectomy can result in increased oxygen consumption, atelectasis, pneumonia, decreased vital capacity, and increased morbidity and mortality. The aim of this study was to compare the analgesic effects of intrapleural meperidine and intravenous morphine in controlling post-cholecystectomy pain. MATERIALS AND METHODS: In a double-blinded randomized clinical trial, 72 patients who were candidate for elective open cholecystectomy, were divided randomly into two groups based on accidental randomized numbers. Anesthesia technique was precisely the same for all patients. At the end of surgery, 50 mg of meperidine (diluted in 20 cc normal saline) was injected intrapleurally for meperidine group patients; whereas, 0.1 mg/kg intravenous morphine was injected intravenously in control group. Onset of pain and total dose of rescue analgesic were measured. RESULTS: In order to obtain a Numerical Rating Scale (NRS) <3, the difference in morphine consumption up to 12 hours in two groups (4.4 ±1.7 mg in meperidine group & 5±2 mg in control group) was not statistically different. However, the first request for analgesia in meperidine group was delayed significantly longer than the control group (146.6 ±6.8 minutes in meperidine group & 40 ±1.8 minutes in control group). CONCLUSION: A single injection of intrapleural meperidine can delay the first request for analgesia in open cholecystectomy compared to intravenous morphine.

Improving the Training Process of Anesthesiology Residents Through the Mentorship-Based Approach.

BACKGROUND: Although mentoring has been accepted as an effective and nourishing component in medical learning, known mentoring programs for the residents are lacking in most countries. OBJECTIVES: To evaluate the mentoring program for anesthesiology residents at Shahid Beheshti University, an examination was designed to explore the styles of mentoring programs, as well as the aims and outcome followed by such programs. METHODS: In October 2016, Anesthesiology Department of Shahid Beheshti University of Medical Sciences enrolled all the nine educational wards in "mentorship program". Twelve members of the faculty were chosen to be mentor. This program contained: (a) Creating online groups for reporting, feedbacks, and problem-solving, (b) integrating each chapter of textbooks for studying program each month, (c) establishing formative and summative assessments (i.e., PMP, OSCE, multiple choice exams), (d) role-playing for stress management of level 4 residents. Our main objective was to provide the residents with the provision of mentors. The goals of our programs were: Arrange a safe environment to encourage and foster reflection, promote self-care and wellness, guide special development, provide a resource for residents pursuing control, enrich team constructing and problem-solving skills, and promotion in career counseling of anesthesia residents at Shahid Beheshti University of Medical Sciences enrolled in this program from 2014 to 2017. We retrospectively compared 2 periods before (2014 - 2015) and after (2016 - 2017) of monthly examination and educational conference. RESULTS: In the academic stage from 2014 - 2015, the overall first-time license rate for the IBA written QE was 7 of 14 (50%) and in the period of 2016 - 2017, the general rate was 11 of 14 (78%) and in the period of 2017 - 2018, it was 12 of 14 (85%). For each extra year experiencing the program, the odds ratio for passing IBA written QE was 1.7 (P < 0.05). The median Iranian Board of Anesthesiology In-Training Examination (IBAITE) percentile was considerably greater in period 2 than period 1 (P < 0.05). Also, there was a significant correlation between IBAITE score and first-time passing rates for the IBA written QE (0.55, P < 0.05). CONCLUSIONS: The results of this study demonstrated the clinical mentorship program as an effective method in improving theoretical, clinical, and professional achievement of anesthesiology residents. Programmed mentorship could significantly improve the educational goal achievements for anesthesiology residents. Mentoring programs are needed to be more used; however, need to be assessed and evaluated, especially regarding the professional aspects of education. Medical schools could subsequently be assessed regarding the number and quality of their running mentorship programs as a quality improvement tool.

Spinal Anesthesia for Renal Transplantation in Lung Resected Patient: A Case Report.

Renal transplantation is among the definitive therapies for treatment of patients with "End-Stage Renal Disease" (ESRD). Proper anesthesia should be considered in patients who undergo renal transplantation. On the other hand, anesthesia in patients with single lung is an ever challenging issue. In this case report, we introduce a 42 year old woman with "Autosomal Dominant Polycystic Kidney Disease" (ADPKD) who was candidate for renal transplantation and underwent regional anesthesia since she had one lung. The patient had bilateral renal resection 4 years ago (due to ADPKD) and was undergoing dialysis 3 times weekly. Thirty five years ago, left lung resection had been done for the patient (due to suspected Tuberculosis). This patient demonstrated our experience in management of regional anesthesia as a safe method in patients with single lung who would undergo renal transplantation.

Carbamazepine effects on pain management and serum IL-6, IL-10 evaluation in addicted patients undergoing surgery.

Postoperative pain control remains an important issue in the field of surgery. Assessing and managing patients with acute pain who are addicted to opioids are often challenging. It has been shown that, addicted patients are less tolerant to pain. There is limited evidence to guide the management of acute pain in these patients. Here we studied the effect of preemptive use of carbamazepine on pain behavior and serum IL-6, IL-10 levels in the addicted patients. 90 male patients (25-45 years, BMI 20-27), were divided into 3 group of 30 patients: 1- control, 2- addicted, 3- addicted patients receiving carbamazepine 400mg before surgery. The visual analog pain scale and serum levels of IL-6 and IL-10 were evaluated at time 0 (before surgery), 1 and 12h postoperatively. Compared with control and carbamazepine groups, addicted patients exhibited exaggerated pain behavior before and after surgery, however, postoperatively, a significant increase in pain behavior was seen in control compared to carbamazepine group. A decrease in serum IL-10 and an increase in IL-6 concentrations were observed in addicted patients. In the morphine abuser, a decrease in pain threshold, an increase in IL-6 and a decrease in IL-10 levels were evident compared with non-abuser subjects. Addition of carbamazepine improved pain sensation and serum IL-6 levels and a reduction in serum IL-10 level in control patients was paralleled to their recovery. It seems that, preemptive use of low dose of carbamazepine can improve postoperative pain and cytokine activities in the addicted patients.

Dexmedetomidine could enhance surgical satisfaction in Trans-sphenoidal resection of pituitary adenoma.

BACKGROUND: Excessive bleeding is an unwanted complication of trans-sphenoidal resection of pituitary adenoma due to increases in intracranial pressure (ICP) and hemodynamic instability. Dexmedetomidine (Dex) anα2-agonists is the drug of choice in intensive care units (ICU) and cardiac surgeries to control abrupt changes in hemodynamic. Severe cardiovascular responses occur during trans-sphenoidal resection (TSR) of the pituitary adenoma despite adequate depth of anesthesia. The aim of this paper was to determine the effect of Dexmedetomidine on bleeding as primary outcome, and surgeon's satisfaction and hemodynamic stability as secondary outcomes in patients undergoing trans-sphenoidal resection of pituitary adenoma. METHODS: Total numbers of 60 patients between 18-65 years old and candidate for elective trans-sphenoidal resection of pituitary adenoma were randomLy allocated to two groups; Dexmedetomidine infusion (0.6µg/kg/hour) or normal saline infusion. Mean arterial pressure (MAP), heart rate (HR), dose of hypnotics and narcotics during surgery, bleeding, and surgeon's satisfaction were recorded. RESULTS: Propofol maintenance dose (µg/kg/min) and total Fentanyl use (µg) were significantly lower in Dex group compare to control group (P=0.01 and 0.003, respectively). Total bleeding amount during operation in Dex group was significantly lower than control group (P=0.012). Surgeon's satisfaction was significantly higher in Dex group at the end of surgery. MAP and heart rate throughout surgery were significantly lower in Dex group compare to control group (P=0.001). CONCLUSIONS: Dexmedetomidine infusion (0.6µg/kg/hour) could reduce bleeding and provide surgeon's satisfaction during trans-sphenoidal resection of pituitary adenoma.

Intrathecal Dexmedetomidine and Fentanyl as Adjuvant to Bupivacaine on Duration of Spinal Block in Addicted Patients.

BACKGROUND: Addicted patients have innate tolerance to local anesthetics in both neuraxial and peripheral blocks. Dexmedetomidine (Dex) is a highly selective α2 adrenergic receptor agonist used as additive to increase quality and duration of peripheral nerve blocks. OBJECTIVES: The current study aimed to compare the effect of dexmedetomidine and fentanyl additives on bupivacaine to prolong the duration of block and minimizing side effects. PATIENTS AND METHODS: Patients were candidates for elective surgery less than three hours of lower abdomen or lower extremities surgeries. Patients were randomly allocated to receive dexmedetomidine 5 µg added to 12.5 mg (2.5 mL) of 0.5% hyperbaric bupivacaine (DEX group), or 25 µg (0.5 mL) fentanyl added to 12.5 mg (2.5 mL) of 0.5% hyperbaric bupivacaine (F group) or only 12.5 mg of 0.5% hyperbaric bupivacaine. Data were recorded based on sensory block. Motor block was tested using modified Bromage scale every 30 minutes until the end of block. Time to return of sensory block to 4 dermatomes below and time to return of Bromage scale to 0 were recorded. All vital measurements (oxygen saturation, heart rate, electrocardiogram, and non-invasive blood pressure) were performed at 0, 30, 60, 90, 120 and 180 minutes in all three groups of the study. Group DEX received dexmedetomidine additive and group F received fentanyl additive and group C (control) received normal saline. RESULTS: Totally, 84 patients were randomly divided into three groups of 28 patients. Onset of sensory block in DEX group was significantly lower than those of fentanyl (P = 0.012) and control groups (P = 0.001). Duration of sensory block was significantly longer in DEX group compared to Fentanyl (P = 0.043) and control (P = 0.016) groups. Duration of motor block in the DEX group was significantly longer than those of the fentanyl (P = 0.014) and control groups. Heart rate and mean arterial pressure were significantly higher in the DEX group at 30, 60, 90,120, and 180 minutes compared to those of the other two groups (P < 0.05). CONCLUSIONS: Dexmedetomidine added to bupivacaine in spinal anesthesia is more effective to increase duration of block, providing more appropriate sedation and less postoperative pain scale and post-operative nausea and vomiting (PONV) compared to fentanyl additive.

Foreign Body Stocked between Vocal Cords.

Foreign body (FB) aspiration is a rare event in adults and can mimic other pathologies such as refractory asthma. Most of the objects can be removed using a bronchoscope. Herein, we present a unique case of aspiration of a FB stocked between vocal cords for one week and the anesthetic considerations.

The effect of anesthesia method on serum level of pro-brain natriuretic Peptide in patients undergoing orthopedic surgery.

BACKGROUND: Surgical stress response is among the most severe stress tolerated by the patient, which needs suppression by anesthesia. OBJECTIVES: We assessed the effect of three methods of anesthesia on postoperative levels of pro-brain natriuretic peptide (pro-BNP) to determine the most effective one in preventing surgical stress response. PATIENTS AND METHODS: In a randomized clinical trial, 120 patients who were 18 to 65 years old and met inclusion and exclusion criteria were selected and randomly allocated to three groups of 40:Group A, general anesthesia plus epidural catheter; Group B, general anesthesia and intravenous patient-controlled analgesia; and Group C, spinal anesthesia plus intravenous patient-controlled analgesia. RESULTS: There was no difference between three groups for basic characteristics and variables and baseline pro-BNP levels; however, postoperative pro-BNP levels in Groups A, B, and C were respectively63.8 ± 10.1, 83.2 ± 12.3, and 51.5 ± 8.5 ng/L (ANOVA, P = 0.01). CONCLUSIONS: The results of the current study suggested that spinal anesthesia plus intravenous patient-controlled analgesia have the most favorable cardiac effects regarding postoperative levels of pro-BNP.