Vol 6 No 4 (2020): Autumn
Comparison the Efficacy of EMLA Cream versus EMLA with High Frequency Sonophoresis in Decreasing Onset Time to Topical Anaesthesia in Adult Volunteers: A Pilot Study
Background: Sonophoresis or phonophoresis is a well-known transdermal drug delivery mechanism. Usage of high frequency ultrasound for sonophoresis was initiated in late 1950s while the usage of low-frequency sonophoresis was investigated significantly during the past two decades. The objective was to analyze the efficacy of high frequency ultrasound probe in the penetration of EMLA cream in decreasing onset time for topical anaesthesia in adult healthy volunteers.
Methods: A prospective, open labelled, comparative study was conducted on patients reporting at the Pain Clinic our institute. Subjects received the intervention USG probe with EMLA either on the left or the right hand based on a random number chart, with the other hand of the same subject acting as a control. In group USG, the probe was applied directly on the cream without any added pressure. Sensory testing was done every 10 minutes by pin prick on both the hands of the patients NRS scores of both the hands were recorded at 10.20,30 and 40 minutes.
Results: Total 20 patients were selected for the study. Although a significant decrease in the pain scores in both the groups was observed after 40minutes, (p<0.05) both the groups are comparable at each point of time. We could not find any significant decrease in pain scores when groups are compared in intervals during the study period.
Conclusion: There is no significant difference in decreasing the intensity of pain scores upon application of ultrasound over EMLA in an adult population. Further studies have to be done to prove the efficacy in a larger population and pediatric ones
Hyperglycemic Response of Non-diabetic Women Undergoing Abdominal Hysterectomy Who Have Received Prophylactic Dexamethasone to Alleviate Nausea and Vomiting
Background: This study has been designed to assess the hyperglycemic response in non-diabetic patients in women undergoing abdominal hysterectomy; who have received a prophylactic dose of dexamethasone to alleviate post-operative nausea and vomiting (PONV).
Methods: This was a double blind randomized clinical trial involving seventy women who were candidates for abdominal hysterectomy. The women were randomly assigned into two groups. Group A received 8mgs (in 50 mls normal saline) of IV dexamethasone; post-anesthetic induction and pre-surgery. Group B received 50 mls of normal saline post-anesthetic induction and pre-surgery. Patients were asked whether they had any nausea and vomiting during recovery. The patients’ blood sugar (BS) levels were assessed before surgery, during recovery and then 1, 6, 12, 18, and 24 hours after surgery.
Results: Thirty-three women in each group were monitored. Assessment of the results indicates that nausea and vomiting were not significantly different between the two groups. The age and BS before surgery of the patients were not significantly different. BS levels after surgery were significantly higher for the group receiving dexamethasone; with the exception of the levels during the first hour.
Conclusion: The BS of women undergoing abdominal hysterectomy is significantly higher for those receiving a single dose of dexamethasone, post-operatively, compared to patients receiving a placebo. The finding of this study does not support the role of dexamethasone in the prophylactic anti-emetic treatment in abdominal hysterectomy.
An Investigation of the Relationship between Anthropometry (Height, Weight and Body Mass Index) and Incidence of Low Back Pain Following Spinal Anesthesia in Elective and Emergency Surgical Procedures
Background: The incidence of low back pain in adults after spinal anesthesia is rather similar to that of general anesthesia. The pain is often mild with an increased incidence of low back pain that rarely spreads to the lower extremities but persists for several days after surgery. Fear of complications of back pain after neuraxial injection is one the main reason for patient’s refusal of neuraxial anesthesia. Some studies repoted obesity and BMI above 32 as risk factors for low back pain after surgery.
In this study, we aimed to investigate the relationship between selected parameters of body composition, including the amount of total body fat and muscular tissue, and the incidence of low back pain after spinal anesthesia.
Methods: A cross-sectional study was carried out on 100 patients who were candidates for elective or emergency surgery under spinal anesthesia. At first demographic data, a history of back pain and assessment and anthropometric assessment was asked. The history of back pain and intensity of pain were asked after one day, one month and 4 months after surgery. Then the relationship between pain intensity and anthropometric data were assessed.
Results: The mean pain intensity in the normal weight group was 1.3 ± 0.63. In the overweight group, the mean pain intensity was 1.1 ± 0.41. In the obese group, the mean pain intensity was 2.2± 1.2.
Regarding the relationship between mean pain intensity and weight, BMI, and anthropometry, the incidence of pain was not related to patients' anthropometry; the mean pain intensity of these groups were compared; and the incidence of pain was not dependent on weight, BMI, and anthropometry (p-value= 0.4).
Conclusion: Based on the obtained results, it can be concluded that no correlation exists between the incidence of low back pain and mean severity of pain and anthropometric indicators such as BMI, however, low back pain lasted longer in obese patients, which requires further study to investigate the exact nature of such a relationship.
Comparison of the Skill of Emergency Medical Technicians in Terms of Advanced Airway Management Using Endotracheal Tube versus Laryngeal Mask Airway in an OSCE Using a Mannequin
Background: Supraglottic airway management tools such as the laryngeal mask airway (LMA) have recently emerged as the first choice in pre-hospital and hospital airway management guidelines as well as an alternative strategy after endotracheal tube (ETT) placement failure. However, the pros and cons of the LMA compared to endotracheal intubation are still debated.
Given that no study has been conducted to date on the skills of emergency medical technician (EMT) in airway management using LMA compared to endotracheal intubation, we decided to do a study in this regard.
Methods: In this objective structured clinical examination (OSCE), EMTs who had a degree of associate or bachelor were participated. The examiner asked the examinees the required information and entered it in the pre-prepared checklists. The participants took part in a two-stage exam. In the first stage, the airway management of the simulated trauma patient was performed by endotracheal intubation, and in the second stage, the same scenario was performed with LMA. At each stage, the examiner evaluated the examinee's performance in 4 fields of Preparation, Pre-oxygenation, Position and Placement, and Post-intubation management using a standard checklist. In addition, the duration of the procedure from the beginning to the time of fixing the ETT or LMA was recorded and compared.
Results: Totally, 105 EMTs participated in this study, of whom, 102 were male (97.1%). The mean age of the subjects was 36.4± 7.3 years old. Of the total participants, 72 passed both practical exams successfully, and they generally insert the LMA faster; so that the duration of intubation and LMA insertion in 1.4% and 30.6% were <1 min, respectively (p< 0.001). However, no significant difference was observed in terms of the mean time (p= 0.427).
Conclusion: In the present study, the skills of the technicians participating in the study in performing advanced airway procedures were moderate, and also, it was found that their skills in LMA insertion were less than endotracheal tube insertion.
Accurate Tidal Volume for Patients under Mechanical Ventilation: A Cross-sectional Descriptive Study
Background: In order to prevent lung injury among patients under mechanical ventilation, tidal volume should be determined based on predicted body weight. The aim of the study was to determine the accuracy of tidal volume determination for patients under mechanical ventilation and to assess nurses’ knowledge about accurate tidal volume determination.
Methods: This was a cross-sectional descriptive study. This study was conducted on 250 patients under mechanical ventilation and 75 nurses who provided care to the patients. Patients’ height was estimated based on their ulna length and then, their predicted body weight and tidal volume were estimated. Nurses’ knowledge about tidal volume determination was also assessed.
Results: The mean of delivered tidal volume was 9.1±1.73 mL/kg of predicted body weight. Tidal volume for 172 patients (68.8%) had been set at more than 8 mL/kg of predicted body weight. Forty nine nurses (65.3%) noted that there was no guideline in their wards for height and weight measurement. They determined patients’ weight and height through either visual estimation (21 nurses; 28.0%) or asking from their colleagues, patients, or patients’ family members (48 nurses; 64.0%).
Conclusion: Nurses have limited knowledge about accurate tidal volume determination and hence, deliver high tidal volume to patients under mechanical ventilation which puts them at risk for ventilator-associated lung injury. Urgent interventions such as lung-protective strategies, staff training, and careful managerial supervision are needed to prevent ventilator-associated lung injury and improve patient safety.
Effect of Preoperative Dexmedetomidine on Prevalence of Postoperative Cognitive Dysfunction in Elderly Patients Candidate for Orthopedic Surgery under General Anesthesia
Background: Postoperative cognitive dysfunction (POCD) is amongst the most critical complications after surgery. This study shows the effect of dexmedetomidine on the prevalence of postoperative cognitive impairment.
Methods: In this double-blinded clinical trial study, patients aged 60-80 years undergoing pelvic and femoral orthopedic surgery were randomly assigned in one of the two groups of the course, i.e., Dexmedetomidine (DEX) or normal saline (NS). We infuse One hour before anesthesia, one µg/kg dexmedetomidine in the group (DEX), and the same volume of normal saline (NS). Mini-Mental State Examination test (MMSE) was applied to evaluate the patients' cognitive condition, One day before the surgery, 24 and 72 hours after the surgery.
Results: There was no significant difference between the two groups in terms of age, sex, duration of anesthesia, duration of surgery, and the amount of bleeding during operation (P>0.0). The postoperative hematocrit level was lower than the preoperative level in the group (DEX) (P<0.05). There was no significant difference in MMSE test scores pre and postoperatively between the two groups (P>0.05).
Conclusion: Dexmedetomidine infused before surgery has no preventive effect on POCD in elderly patients undergoing pelvic and femoral orthopedic surgery under general anesthesia.
Comparison Outcomes of Anesthesia and Hospitalization of Endovascular Treatment versus Open Surgery for Infra Renal Abdominal Aortic Aneurysm at Sina Hospital from 2011 to 2019
Background: Two methods of repair are currently available for an abdominal aortic aneurysm (AAA), open aneurysm surgery, and endovascular aneurysm repair (EVAR). The purpose of this article is to investigate and compare the outcomes of all cases of open surgery versus EVAR conducted from2011 to 2019 at Sina Medical Research and Training Hospital, the first EVAR was conducted at Sina Hospital in 2011.
Methods: This research is a retrospective cross-sectional study. The study population consisted of all abdominal aortic aneurysm patients who were treated at Sina Hospital in Tehran from September 2011 to December 2019. All patients who met the inclusion criteria participated in the study. A checklist of required data was prepared and used to extract data from patients' medical case files. Patients' information was completed via telephone contact with patients or their families. Analyses were performed using SPSS software with a 5-percent error rate.
Results: The sample consisted of 194 patients who were divided into two groups. 73 patients (37.6%) underwent open surgery and 121 patients (62.4%) underwent EVAR. All patients (100%) who underwent open surgery received general anesthesia, while only 15 patients (12.8%) who underwent EVAR received general anesthesia, and 102 patients (87.2%) who underwent EVAR received spinal anesthesia. Rates of blood loss and blood transfusion, length of stay in the intensive care unit (ICU), the total length of postoperative hospitalization for patients who underwent open surgery were significantly higher than for those who underwent EVAR (P-value <0.001). The mortality probability of patients with a history of CVA and smoking was3.47 and 2.66 times higher than those with a negative history of these cases, respectively. Although average EF was higher in living patients compared to deceased ones, this difference was not statistically significant (P-value= 0.161).
Conclusion: Surgery duration, length of stay in ICU, length of hospital stay, and rate of blood transfusion of patients undergoing EVAR was reduced in comparison with those undergoing open surgery.
Anesthetic Management of a Parturient with Spinal Muscle Atrophy for Cesarean Section: A Case Report
Spinal muscular atrophy is a rare genetic neuromuscular disease characterized by loss of anterior horn cells of spinal cord and brain stem nuclei, resulting in progressive muscle weakness. Anesthesia for these patients is risky because of the risk of worsening of muscle weakness and consequent postoperative respiratory complications. We report anesthesia management in a nulliparous parturient with type 3 disease who underwent urgent cesarean delivery due to progressive decline of amniotic fluid index.
Severe acute respiratory syndrome corona virus 2 acts through angiotensin converting enzyme-2 (ACE-2) receptors and involves multiple organ systems. Also associated with many upper airway symptoms, we reported an unnoticed complication of the upper airway, which presented as hoarseness of voice and throat discomfort during ICU stay, the upper airway flexible endoscopy was performed, which showed vocal cord nodule. The patient was managed conservatively, by improving hydration, steam inhalation, voice rest, and speech therapy. Gradually, there was a significant improvement in patient's symptoms and voice quality. An early prediction and risk mitigation can prevent this complication.