Ali Shahriari

A comparison of tramadol and pethidine analgesia on the duration of labour: A randomised clinical trial

Background: The ideal obstetric analgesia should provide analgesic efficacy without attenuation of uterine contractions.

Effect of Chronic Morphine Consumption on Synaptic Plasticity of Rat’s Hippocampus: A Transmission Electron Microscopy Study

It is well known that the synapses undergo some changes in the brain during the course of normal life and under certain pathological or experimental circumstances. One of the main goals of numerous researchers has been to find the reasons for these structural changes. In the present study, we investigated the effects of chronic morphine consumption on synaptic plasticity, postsynaptic density thickness, and synaptic curvatures of hippocampus CA1 area of rats. So for reaching these goals, 24 N-Mary male rats were randomly divided into three groups, morphine (n = 8), placebo (n = 8), and control (n = 8) groups. In the morphine group, complex of morphine (0.1, 0.2, 0.3, and 0.4) mg/mL and in the placebo (sucrose) group complex of sucrose (% 0.3) were used for 21 days. After the end of drug treatment the animals were scarified and perfused intracardinally and finally the CA1 hippocampal samples were taken for ultrastructural studies, and then the obtained data were analyzed by SPSS and one-way analysis of variance. Our data indicated that synaptic numbers per nm3 change significantly in morphine group compared to the other two groups (placebo and control) (P < 0.001) and also statistical analysis revealed a significant difference between groups in terms of thickness of postsynaptic density (P < 0.001) and synaptic curvature (P < 0.007). It seems that morphine dependence in rats plays a main role in the ultrastructural changes of hippocampus.

Amlodipine and the Successful Management of Post-Electroconvulsive Therapy Agitation.

Electroconvulsive therapy (ECT) is a highly effective nonpharmacologic treatment for the management of depression and some other psychiatric disorders. Post-ECT agitation occurs in up to 12% of ECT treatments and is characterized by motor restlessness, irritability, disorientation, and panic-like behaviors. The severity of post-ECT agitation ranges from mild and self-limited to serious and severe forms requiring prompt medical intervention to protect the patient and the medical staff. In severe agitation medical management may be necessary which consists of using sedative agents, either benzodiazepines or propofol. The side-effects of these sedative agents, especially in the elderly population, necessitate finding ways that could help the prevention of the occurrence of agitation after ECT treatments. We report a 68-year-old female with major depression who was referred for ECT. She experienced severe post-ECT agitation requiring medical intervention after all ECT treatments. Administering of oral amlodipine (5 mg) one hour before ECT treatment successfully prevented the occurrence of post-ECT agitation in this patient. We briefly discuss the possible underlying mechanisms and pathophysiology of amlodipine in the prevention of post-ECT agitation.

The Rate and Severity of Headache after Caesarean Section under SpinalAnaesthesia are decreased by Hypertonic Solutions: A Randomized Placebo-Controlled Clinical Trial

Aim: To determine the frequency and severity of post-dural puncture headache (PDPH) in women undergoing spinal anaesthesia for caesarean section who received an infusion of Voluven or Ringer before the procedure. Methods: We enrolled 240 full term women scheduled for elective caesarean section in this study. Participants were randomly allocated equally to Ringer (A) and Voluven (B) groups. After arrival in the operating room 500 ml of ringer solution was infused within 10-15 min before spinal block in the Ringer group, but in the Voluven group 500 ml of 6% Hydroxyethyl starch solution was infused to the patients. The frequency and severity of headache were compared between two groups. Results: The frequency of PDPH was higher in patients in Ringer group compared to Voluven group at first day (P=0.01), but there were no significant differences between two groups in second (p=0.23) and third days (p=0.30). The severity of headache in Ringer group was significantly more than patients in Voluven group in every three days significantly. Hypotension occurred in 95 patients in Ringer Group (79.17%) and in 76 patients in Voluven Group (%63.33) (P=0.007). The frequency of nausea and vomiting was seen in 27 patients in Ringer group (22.5%) vs. in 18 patients in Voluven group (15%) (p=0.10). Conclusion: Hydration with hypertonic solutions (Voluven) before caesarean section under spinal anaesthesia can decrease the rate and severity of PDPH compared with hydration with Ringer solution.

The Rate of Headache after Caesarean Section and the Size of Needle for Spinal Anesthesia: Clinical Trial

Aim: The rate of postdural puncture headache (PDPH) was compared after caesarean section with spinal anesthesia using the 25 gauge spinal needle with the 27 gauge. Methods: Present study is a randomized clinical trial and 220 full term women entered for caesarean section. We entered full term women randomly for spinal anesthesia with the 25 gauge (group A) and 27 gauge (group B) Quincke spinal needles. In 3 postoperative days, we fallowed and compared Participants in 2 groups for the rate and severity of PDPH. PDPH was defined occipital or frontal headache that made hard the position on sitting or standing. Results: Data of 220 patients were analyzed. The rate of PDPH was significantly higher in women in group A compared to group B at first (P=0.015), second (P=0.037) and third (P=0.005) follow up days. The severity of the PDPH was not significantly different between 2 groups in three follow up days. The rate of success in spinal anesthesia achievement was not significantly different between 2 groups. Conclusion: The results of present study recommended that the size of spinal needle can effect on the rate of PDPH after caesarean section.

Corrigendum to “Effect of Chronic Morphine Consumption on Synaptic Plasticity of Rat’s Hippocampus: A Transmission Electron Microscopy Study”

[This corrects the article DOI: 10.1155/2013/290414.].

Sublingual misoprostol plus laminaria for cervical preparation before surgical management of late first trimester missed abortions, a randomized controlled trial.

Abstract Objective: Comparing the efficacy of low-dose sublingual misoprostol plus laminaria to medium-dose sublingual misoprostol alone for cervical dilation before surgical management of late first trimester missed abortions. Methods: Randomized, controlled trial evaluated 70 women with missed abortion, admitted for surgical termination of pregnancy. The patients were randomly assigned to receive 200 μg sublingual misoprostol with cervical laminaria (intervention group) or 400 μg sublingual misoprostol without laminaria (control group), four hours before surgical process. The study is registered at www.irct.ir (IRCT2014070711020N4). Results: More patients in the intervention group achieved the desired cervical dilation (≥Hegar7) before surgical process than the control group (91.4% versus 17.1%, p < 0.001). Patients in the intervention group experienced less pain during the waiting period (mean Visual Analog Scale scores: 30.8 ± 3.7 versus 43.7 ± 5.9, p < 0.001), and had higher satisfaction level (highly satisfied: 97.1% versus 77.1%, p = 0.02). Four patients in the intervention group and none in the control group had spontaneous expulsion of pregnancy products (p = 0.11). Conclusions: Compared to medium-dose sublingual misoprostol alone, using a combination of cervical laminaria plus low-dose sublingual misoprostol before surgical process is associated with significantly more effective and rapid cervical dilation, lower requirement for mechanical dilation, lower abdominal pain and discomfort during the waiting period and higher patients’ satisfaction.

Post-Spinal Headache: A New Possible Pathophysiology

Post-Spinal Headache: A New Possible Pathophysiology Ali Shahriari, and Mahdi Sheikh Department of Anesthesiology, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran Corresponding author: Ali Shahriari, Department of Anesthesiology, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran. P.O. Box: 1419733141. Tel: +98-9128481663, Fax: +98-2122834332, E-mail: ashahriari@tums.ac.ir

IS THE PRESSURE CONTROL MODE FOR PEDIATRIC ANESTHESIA MACHINES REALLY REQUIRED

Dear Editor, Choosing an appropriate anesthesia machine for mechanical ventilation of pediatric patients is of paramount importance because small changes in the fractions of the delivered tidal volume can cause a significant difference from the desired tidal volume. The anesthesia machines have classically been divided up into pressure or volume controlled modes, with two main characteristics; the limit (what determines the size of the breath), and the cycle (what actually ends the breath). The traditional anesthesia machines with volume controlled mode are not able to deliver precisely small tidal volumes to the pediatric patients. In the traditional anesthesia machines, fresh gas directly streams to the breathing circuit, so if 6 L/min of fresh gas is added to the previous setting (6 liters/60 seconds) 100 mL/s will be added to the delivered tidal volume, and if the inspiratory time is 2 seconds, 200 mL will be added to the tidal volume. These differences significantly increase the desired tidal volume. Therefore, the conventional anesthesia machines with the volume-controlled ventilation mode are not suitable to deliver a tidal volume less than 200 mL. During ventilation of neonates or children (in which tidal volume is less than 200 cc, respiratory rate is at least 16 - 20/minute and with a 1:2 I/E ratio, inspiratory time is less than 1 second), these differences are not acceptable. Thus, anesthesiologists usually use pressure-controlled ventilation rather than volume-controlled ventilation for pediatric anesthesia. A pressure-limited, time-cycled pulmonary ventilator includes a pressurized gas system that supplies respiratory gas to a patient at a selected inspiratory flow rate; an exhalation valve that opens an expiratory flow path in response to the elapsing of a selected inspiratory time period, and maintains a selected proximal pressure limit during the inspiratory time period. The tidal volume that results from a pressure-targeted machine is attributable to the set inspiratory pressure and patient’s lung-thorax compliance. Circuit compliance, fresh gas flow changes, and even small leaks around an un-cuffed endotracheal tube do not modify the delivered tidal volume (1). Pressure-controlled ventilation offers the advantage of limiting barotrauma in the condition of changing lung compliance, but a decrease in tidal volume will occur in the pressure-controlled ventilation mode, when the compliance of the lung is decreased or a pressure against the abdomen is created (e.g. in laparoscopic surgeries) (2). There are also some pediatric ventilators that deliver the breath by setting the inspiratory and expiratory duration and setting the flow of gas, but management of patients with these ventilators can lead to hypoventilation in the circumstance of increasing of the pulmonary resistance or reversal of muscle relaxants. To deliver a precise tidal volume, some new anesthesia machines have equipped with fresh gas decoupling valves. In these machines, the fresh gas (FGF) is not delivered to the inspiratory limb during inspiration. Practically, it means that FGF does not increase the tidal volume. The function of the fresh gas decoupling valve is to provide a precise delivery of the set tidal volume unaffected by varying fresh gas flow rates. During the inspiratory phase of ventilation, the valve closes, allowing only gas from the ventilator piston chamber to be delivered through the inspiratory branch to the patient. During the expiratory phase, the valve opens, allowing the ventilator piston chamber to fill with a mixture of the exhaled gas that has passed through the absorber and fresh gas (3). A second method for accurate delivery of desired tidal volume is compliance compensation, to replace volume lost to the breathing tubes. A potentially large percentage of the bellows volume is lost into the breathing circuit, secondary to compliance and compression. Leaks and sampled gas flow will further reduce desired tidal volume (4). To ensure that the set tidal volume will be delivered to the patients, new anesthesia machines involve a preuse leak and compliance test during which the end of the circuit must be occluded. The total compliance will be measured and the machine use this data to adjust piston or bellows movement, according to desired pressure airway setting (5). The anesthesiologist can use volume-controlled ventilation by a modern anesthesia machine that equipped with fresh gas decoupling valves and compliance and fresh gas compensation technology with confidence. Minimal tidal volume as low as 30 mL can be delivered precisely (5). The anesthesiologist should not persist in ordering a ventilator with multiple ventilation modes. Rather, choosing a ventilator with a unique mode that delivers a precise tidal volume would be suitable.