Journal of Anesthesiology and Pain

---

Background and aims
Narcotics are commonly used in controlling of the postoperative pain. But few studies are available about direct narcotic spillage into surgical field. The aim of this study was to check the efficacy of this method for analgesia in postoperative lumbar microdiscectomy.
Methods
In a randomized clinical trial, numbers of 100 patients were included into two equal groups due to low back radicular pain and, underwent microdiscectomy. Study group received direct morphine (2mg/5mL) spillage and control group received normal saline (5mL) spillage as a placebo. The main outcome to be compared between trial and placebo groups were: Patient comfort rate in recovery room and ward, amount of analgesics used, postoperative ambulation time, post operative hospitalization days.
Results
Mean Systolic blood pressure increment was lower in morphine group.
The restlessness and agitation during recovery in study group was lower than control group. Only %6 of patients in study group compared to %98 in placebo group had either moderate or severe pain, six hours after operation.
Mean morphine dose used for study group was 10.75 mg compared to 21.4 mg among control group patients (p<0.0001). Mean ambulation time was 2 days among study group patients compared to 2.6 days in control group. Mean hospitalization length was 4.7 and 7 days in study and control group respectively.
Conclusion
Using epidural morphine spillage (EMS) during Lumbar microdiscectomy results in better control of postoperative pain, early ambulation of patients and decreased hospitalization length.

---

Background &aim: Several reasons cause to pain in ICU patients. The pain brings some side effects in the patients so that different methods have been introduced for pain reduction. The aim of this study was comparison the effect of epidural fentanyl injection with intravenous fentanyl injection for analgesia and the effect of these two methods on ICU patients' continuousness level.
Material and methods: This investigation was a single-blind clinical trial in ICU patients of Shahid Bahonar Hospital in Kerman. These patients suffered from abdominal and chest trauma that were mechanically ventilated. Sixty patients were assessed in two groups. Patients in Group A received intravenous fentanyl for first 24 hrs, and then get epidural fentanyl from epidural catheter. Patients in B group were injected by epidural fentanyl in first 24 hrs, and then by intravenous fentanyl in second 24 hrs. Levels of fentanyl were 1.5 mcg.kg^-1 intravenous injection and 8 mcg.kg^-1 for epidural injection that were regulated with injection pump. Glascow Coma Scale and Visual Analogue Pain Score were assessed in 0, 2, 6, 24, 50, 54 and 72 hours.
Results: In both groups, pain score in 2 hours was significantly lower in intravenous injection than epidural way but after 6 hours, epidural way cause to relieve pain than intravenous way (P<0.05). In all items, fentanyl intravenous injection cause to decrease patients GCS than epidural way (P<0.05). There were no significant differences between patient's pain score and GCS with their age, sex, and trauma (abdomen, chest or both of them) (P>0.05).
Conclusion: The best way of pain control in mechanically ventilated patients with abdominal and chest trauma is intravenous injection of fentanyl in the first 2 hours and epidural injection of it in other hours. In addition, intravenous injection of fentanyl always decreases consciousness level more than epidural way.

---

Background: The aim of this study is comparing ACTH changes in epidural and intravenous analgesia technique after lower limb orthopedic surgery.
Methods: In a randomized clinical trial in Hazrat Rasool  Akram Hospital during 1387-88 , 60 patients candidate for surgery on the lower extremities were randomly allocated to receive either postoperative analgesia  with epidural analgesia (PCEA) or IV analgesia (PCIA). Measurement of ACTH levels and Visual analogue scale (VAS) was performed in four relief phases including at the time of arrival to the operating room, immediately after surgery and 12 hours after intravenous pump functionary and 24 hours after surgery were recorded.
Results: The mean level of ACTH and VAS, 24 hours and 12 hours after surgery in the PCEA group were less than PCIA. Ramsey Sedation Score (RSS) in PCEA group at these intervals was more than PCIA cases.
Conclusion: It seems that PCEA relieves pain more effectively than PCIA method. However, the proper method of anesthesia for each patient as well as patients&apos preferences should be considered in selecting the method of postoperative analgesia.

---

Background: The aim of this study is comparing ACTH changes in epidural and intravenous analgesia technique after lower limb orthopedic surgery.
Methods: In a randomized clinical trial in Hazrat Rasool  Akram Hospital during 1387-88 , 60 patients candidate for surgery on the lower extremities were randomly allocated to receive either postoperative analgesia  with epidural analgesia (PCEA) or IV analgesia (PCIA). Measurement of ACTH levels and Visual analogue scale (VAS) was performed in four relief phases including at the time of arrival to the operating room, immediately after surgery and 12 hours after intravenous pump functionary and 24 hours after surgery were recorded.
Results: The mean level of ACTH and VAS, 24 hours and 12 hours after surgery in the PCEA group were less than PCIA. Ramsey Sedation Score (RSS) in PCEA group at these intervals was more than PCIA cases.
Conclusion: It seems that PCEA relieves pain more effectively than PCIA method. However, the proper method of anesthesia for each patient as well as patients' preferences should be considered in selecting the method of postoperative analgesia.

---

Background: Thoracotomy is a particularly painful surgery and good pain control is crucial to maximize the ability to cough and breath. The most common methods of post operative pain management are systemic narcotics and epidural adminstration of local anesthetic agents or narcotics. The purpose of the persent study was to compare postthoracotomy analgesia of extraplural and epidural catheters.
Methods: This is a randomized clinical control trial study performed in Alzahra&aposs hospital of medical university of Isfahan. 64 patients were randomized in two groups.In group A, 15cc %0/125 bupivacaine before surgery and in group B, 10cc %0/5 bupivacaine at the end of surgery were injected and repeated every hour post operatively. Visual analog scale in two group collected and comparcd.
Result: VAS in epidural catleter was better than extra plural catheter but this difference is not significant. (P<0/05). No significant respiratory complication wre reported in both group.
Conclusion: Due to results this difference is related to position, drainage of chest tube, volume of local anesthetic and type of surgery in the extra plural groups. Because of no significant difference between them we can use this techniques based on experience and preference of anesthesiologist and surgeon.

---

Aims and background: Chronic radicular low back pain is usually temporarily relieved by transforaminal epidural(TFE) injection of steroids our aim was to evaluate the effect of TFE dexmedetomidine injection in comparison with steroids in patients with chronic lumbar radicular pain. Materials and methods: Patients with 3 months of low back and leg pain due to intervertebral disc herniation were randomized to receive transforaminal epidural (TFE) injection(s) of 0.2% bupivacaine and either dexmedetomidine (1 mcg/kg) or triamcinolone (20mg). Patients, investigators and study coordinators were blinded to treatment. Primary outcome was visual analogue score (VAS) after the procedure, and functional improvement according to Oswestry disability index(ODI) after 2 weeks, 1, and 6 months. Other outcomes included serum Vitamin D, fasting blood sugar, and bone densitometry which were checked before and after the treatment with an interval of 1 month,3 days, and 6 months, respectively. Findings: Twenty-two patients were screened and enrolled 11 received dexmedetomidine and 11 triamcinolone. Both groups showed significant improvement in pain score after the injection compared to baseline (p< 0.05). The dexmedetomidine group showed additional functional improvement at 1 and 6 months relative to triamcinolonebased upon ODI (p=0.001). Fasting blood sugar was also significantly increased in triamcinolone group in comparison with dexmedetomidine group ( p=0.007).However, as target enrollment was not reached in our study, we cannot say with confidence that dexmedetomidine would surely result in better outcome in patients. Regarding side-effects ,there were no serious complications. Conclusion: Radicular pain due to disc herniation improved rapidly with TFE injection of either dexmedetomidine or triamcinolone. Dexmedetomidine resulted in greater functional improvement, with better side effect profile. Future studies however, would probably determine if dexmedetomidine is superior to placebo and of particular use in those at risk for corticosteroid complications.

---

Epidural anesthesia for cesarean section in a patient with Hypertrophic Cardiomyopathy Aim and Background: The pathophysiologic changes of Hypertrophic Cardiomyopathy is complex and the physiologic changes of pregnancy and anesthesia for cesarean section have a great effect in the hemodynamic and it can even lead to maternal death. We report a 21-year pregnant woman with HCM who were candidate for elective cesarean section. Case report: A21-year-old woman, gestational age 38 weeks, with a history of Hypertrophic Cardiomyopathy who candidate for elective cesarean section.. Epidural anesthesia was performed with lidocaine% 1. The patient was discharged after 72 hours without any complication. Conclusion: We recommend epidural anesthesia with lidocaine for cesarean section in a patient with Hypertrophic Cardiomyopathy. Key words: Cesarean section, Hypertrophic Cardiomyopathy, Epidural anesthesia

---

Background:Pain is a complex medical problem that its inadequate control of postoperative has adverse effects onpatients physiological , metabolic and mentalstatus. Adding new supplements will lead to an increased duration of analgesia . The purpose of this study was to compare the addition of neostigmine and ketamine to bupivacaine 0.25% for epidural analgesiainincreasing duration ofpostoperative analgesia.
Materials and Methods:In this double blind clinical trial, 90 patients over 50 years candidate for elective hip surgerywith ASA class I, II randomly divided to three groups: neostigmine , ketamine and control groups. All patients received epidural with bupivacaine 0.25% by 2cc/segment .Furthermore 60 micrograms neostigmineadded in first group and 40 mg ketamine ingroup II . Level of postoperative pain based on VAS and duration of analgesia and amount of analgesic determined and compared between the three groups .
Results:The mean of  pain score at 6 and 12 hours after surgery was significantly lower in the ketamine group than the other groups and in neostigmine group was less than placebo( P ≤ 0.01). The mean of duration of postoperative analgesia in the ketamine group was significantly higher than the other groups and in neostigmine group was more than placebo(P ≤ 0.01). The mean dose of analgesic (pethedin)  wasthe least in the ketamine group (P ≤ 0.001).
Conclusion:Neostigmine and ketamine with bupivacaine 0.25% for epidural anesthesia increased the duration of analgesia for postoperative and reduced analgesicconsumption that  about ketaminewas more than neostigmine .

---

 Aim and background: Pulse radiofrequency (PRF) is a pain treatment modality, and is used for various painful states in clinical practice. To compare Transforaminal epidural injection of steroid with PRF in the pain in patients with low back radicular pain. Materials and methods: In this single blind randomized clinical trial study, on 42 patients  devided to PRF group and TF group.  Pain Score  were measured by use of VAS, ODI, analgesic requirement,lazec test before the treatment,24 hours, 1 week, 1 mounth, 3 mounths after the treatment. Findings: The successful rate was 100% in PRF group and 23.5% in TF group, that showed significant difference between the groups (p=0.0001). Pain score was significantly decreased in different times in the PRF group (p=0.0001). There was no significant difference in change of ODI and analgesic requirement between the two groups at different times during the follow up (P>0.05). There was no significant difference in propofol administered between the DEX and remifentanil groups in intraoperative time (P>0.05). conclusion: It seems that Pulsed RF treatment is a safe and simple procedure to control radicular pain in the lumbar regions.

---

 Epidural space is a favorite anatomic target for several pain and anesthesia interventions. There are several practical techniques to access and localize the epidural space in routine pain or anesthesia practice. However, high prevalence of false positive results in routine anesthesia techniques, and probability of catastrophic events, in the case of performing pain procedures in false anatomic location, mandates additional application of more sophisticated and accurate radiological approval techniques in epidural space pain interventions.

 

---

 Aims and background: Chronic low back pain is one of the common causes of patients referring to specialized
and general medical clinics. The positive effect of Epidural Steroid injection has been proven in relieving pain in
these patients. In this study, the epidural effects of methylprednisolone acetate in these two methods of Caudal
and Lumbar were compared.
Materials and Methods: In this study, 80 patients with radicular lower limb pain due to lumbar intervertebral
disc protrusion who were referred to the pain clinic were divided into two groups of 40 patients.
In the first group, steroids were injected into the epidural site by Lumbar method and in the second group by
Caudal method. The effects of these two methods on reducing patients’ pain at 2-month intervals and at the end
of 1 year were evaluated and compared.
Results: According to this study, epidural steroid injection significantly reduced the mh pain in patients (P <0.001),
but there was significant difference between Lumbar and Caudal methods. There was no reduction in pain. The
rate of pain reduction in patients one year after epidural steroid injection in both lumbar and Caudal methods was
not related to the level of discopathy. The rate of pain reduction after lumbar epidural steroid injection in patients
with a history of lumbar spine surgery was less than caudal injection (P = 0.043). In Patients with a history of
lumbar spine surgery the injection of caudal steroid would further reduce their pain (P = 0.336). Epidural steroid
injection improves deep tendon reflexes (DTR) anesthesia of the lower extremities
Conclusion: Patients with radicular pain in the lower extremities who have not responded well to medication
can benefit from epidural steroid injections. In reviewing the results of one year, the lumbar or caudal injection
method is not preferable to another. Only in cases where the patient has a history of lumbar spine surgery, the
caudal method will be preferred.

---

Continuous epidural analgesia (CEA) is the most common local anesthesia technique used to control pain after Total knee arthroplasty (TKA). CEA has many side effects. Continuous paravertebral block is an effective method with fewer side effects in controlling TKA pain. The aim of this study was to compare the effect of this two methods on post-TKA pain.TKA patients were randomly divided into two groups (N = 19): A) CEB: Bupivacaine 0.25% was injected epiduraly by pump at 4 ml / hr during 24 hours after surgery. B) Continuous Lumbar Paravertebral Block (CLPB): all interventions were similar to group A, but by paravertebral catheter. Basic Mobility Scale (BMS) and the Visual Analogue Scale (VAS) ( static and dynamic) four times (4, 8, 16 and 24 hours after surgery) were measured and recorded. Use of opioids and their complications were measured.Patients in the CLPB group experienced significantly less dynamic and static pain 4 and 8 hours after TKA than patients in the CEA group (p< 0.05). There was no side effects in patients in the CLPB group but,  patients in the CEA group experienced Nausea and Vomiting. No significant difference was observed for BMS and Muscular Strength in any of the follow-up stages between the two groups (P> 0.05).Continuous paravertebral block has equal efficacy in controlling pain in patients undergoing TKA surgery compared to continuous epidural block. Due to, lack of complications it can be considered as a suitable alternative in TKA patients.