Anatoli Stav

Cervical epidural steroid injection for cervicobrachialgia

Fifty patients with chronic resistant cervicobrachialgia were randomly divided into two groups. Twenty‐five patients (group A) were treated with cervical epidural steroid/lidocaine injections and 17 patients (group B) were treated with steroid/lidocaine injections into the posterior neck muscles. Another eight patients from group B were excluded from the study because they had started the process of litigation of insurance claims and their subjective analysis of pain relief might therefore not be trustworthy. One to three injections were administered at 2‐week intervals according to the clinical response. All patients continued their various pre‐study treatments: non‐steroidal anti‐inflammatory drugs, non‐opioid analgesics and physiotherapy. Pain relief was evaluated by the visual analogue scale 1 week after the last injection and then 1 year later. One week after the last injection we rated pain relief as very good and good in 76% of the patients in group A, as compared to 35.5% of the patients in group B. One year after the treatment 68% of the group A patients still had very good and good pain relief, whereas only 11.8% of group B patients reported this degree of pain relief. These differences were statistically significant. We failed to achieve significant improvement of tendon reflexes or of sensory loss in both groups, but the increase in the range of motion, the fraction of patients who were able to decrease their daily dose of analgesics, and recovery of the capacity for work were significantly better in group A. We encountered no complications in either group of patients. We conclude that cervical epidural steroid/local anaesthetic injection is an effective method for achieving immediate and long‐standing pain relief and improvement in motion and performance in chronic resistant cervicobrachialgia.

Nasal ketamine for paediatric premedication

Ketamine in a dose of 6 mg · kg−1 was nasally administered in 86 healthy children (ASA I and II), aged from two to five years undergoing elective general, urological or plastic surgery, 20 to 40 min before the scheduled surgery time. These children were compared with 62 others, also aged from two to five years, in whom promethazine and meperidine, 1 mg · kg−1 of each, were injected im. Sedation was started as excellent in 48 and as adequate in 19 children in the ketamine group, compared with nine and 12 respectively in Group 2 (P < 0.05), while salivation was similar in both groups. We conclude that nasal ketamine is an alternative to im preanaesthetic sedation administration in children aged from two to five years.RésuméVingt à quarante minutes avant la chirurgie, de la kétamine 6 mg · kg−1 est administrée par voie nasale à 86 enfants en bonne santé (ASA I et II), âgés de deux à cinq ans programmés pour une intervention urologique ou plastique non urgente sous anesthésie générale. On compare ces enfants à 62 autres enfants du même âge, auxquels on a injecté par la voie i.m., soit de la mépéridine, soit de la prométhazine, à la dose de 1 mg · kg−1. La sédation est jugée excellente pour 48 et adéquate pour 19 des enfants du groupe kétamine, comparativement à 9 et 12 des enfants du groupe 2 (P < 0,05), alors que la salivation est identique dans les deux groupes. Nous en concluons que la kétamine nasale est une alternative a la prémédication intramusculaire pour des enfants de deux à cinq ans.

Lidocaine pretreatment effectively decreases the incidence of hiccups during methohexitone administration for dilatation and curettage

The efficacy of lidocaine 1 mg · kg‐1 for prevention of methohexitone‐induced hiccups was assessed in a double‐blind fashion in 200 patients undergoing dilatation and curettage for pregnancy interruption. The patients were randomly assigned to receive either lidocaine 1% or saline 0.9% in a similar way (1 ml for every 10 kg of body weight). The incidence of hiccups was 16% in the control group compared to 6% in the lidocaine group. We speculate that this reduction in the methohexitone‐induced hiccup ratio is related to lidocaines membrane‐stabilizing properties, which decrease the excitability of all the nervous structures involved in this reflex.

Comparison of the Supraclavicular, Infraclavicular and Axillary Approaches for Ultrasound-Guided Brachial Plexus Block for Surgical Anesthesia

Objective We hypothesized that ultrasound (US)-guided technique of the supra- and infraclavicular and axillary approaches of brachial plexus block (BPB) will produce a high quality of surgical anesthesia for operations below the shoulder independently of the approach and body mass index (BMI). Intercostobrachial and medial brachial cutaneous nerves will be blocked separately because they are not a part of the brachial plexus. Methods This is a prospective randomized observer-blinded study. The three approaches of the US-guided BPB without neurostimulation were compared for quality, performance time, and correlation between performance time and BMI. Intercostobrachial and medial brachial cutaneous nerve blocks were used in all patients. Results A total of 101 patients were randomized into three groups: SCL (supraclavicular), ICL (infraclavicular), and AX (axillary). Seven patients were excluded due to various factors. All three groups were similar in demographic data, M:F proportion, preoperative diagnosis and type of surgery, anesthesiologists who performed the block, and surgical staff that performed the surgical intervention. The time between the end of the block performance and the start of the operation was also similar. The quality of the surgical anesthesia and discomfort during the operation were identical following comparison between groups. No direct positive correlation was observed between BMI and the block performance time. The time for the axillary block was slightly longer than the time for the supra- and infraclavicular approaches, but it had no practical clinical significance. Transient Horner syndrome was observed in three patients in the SCL group. No other adverse effects or complications were observed. Conclusions All three approaches can be used for US-guided BPB with similar quality of surgical anesthesia for operations of below the shoulder. A block of the intercostobrachial and medial brachial cutaneous nerves is recommended. Obesity is not a significant factor in relation to the time of US-guided BPB performance, or the quality of surgical anesthesia. (ClinicalTrials.gov number, NCT01442558.)

Premedication with metoclopramide decreases the frequency of methohexital induced hiccup

Metoclopramide is one of many drugs that have been recommended for the treatment of intractable hiccup. Methohexital may produce hiccup during induction of general anesthesia. 211 women received methohexital for induction and maintenance of general anesthesia for short gynaecological procedures. All the patients were premedicated with fentanyl, diazepam and atropine. 109 patients were randomly selected to receive metoclopramide before induction of anesthesia; the remaining 102 patients served as a control group, and were anesthetized without metoclopramide premedication. The frequency of hiccup was compared between the two groups. 7 patients had hiccup in the metoclopramide premedicated group, as compared to 17 patients in the control group. This difference was statistically significant. We conclude that metoclopramide reduces the frequency of methohexital induced hiccup, and recommend that metoclopramide be routinely used for the premedication of methohexital injection.

Transversus Abdominis Plane Versus Ilioinguinal and Iliohypogastric Nerve Blocks for Analgesia Following Open Inguinal Herniorrhaphy.

Objectives We hypothesized that preoperative (pre-op) ultrasound (US)-guided posterior transversus abdominis plane block (TAP) and US-guided ilioinguinal and iliohypogastric nerve block (ILI+IHG) will produce a comparable analgesia after Lichtenstein patch tension-free method of open inguinal hernia repair in adult men. The genital branch of the genitofemoral nerve will be blocked separately. Methods This is a prospective, randomized, controlled, and observer-blinded clinical study. A total of 166 adult men were randomly assigned to one of three groups: a pre-op TAP group, a pre-op ILI+IHG group, and a control group. An intraoperative block of the genital branch of the genitofemoral nerve was performed in all patients in all three groups, followed by postoperative patient-controlled intravenous analgesia with morphine. The pain intensity and morphine consumption immediately after surgery and during the 24 hours after surgery were compared between the groups. Results A total of 149 patients completed the study protocol. The intensity of pain immediately after surgery and morphine consumption were similar in the two “block” groups; however, they were significantly decreased compared with the control group. During the 24 hours after surgery, morphine consumption in the ILI+IHG group decreased compared with the TAP group, as well as in each “block” group versus the control group. Twenty-four hours after surgery, all evaluated parameters were similar. Conclusion Ultrasound-guided ILI+IHG provided better pain control than US-guided posterior TAP following the Lichtenstein patch tension-free method of open inguinal hernia repair in men during 24 hours after surgery. (ClinicalTrials.gov number: NCT01429480.)

Action of opioid agonist-antagonist drugs on the pupil and nociceptive responses in mice.

Opioid derivatives with mixed agonist-antagonist activities are becoming increasingly more popular in analgesia. We tested the mydriatic and analgesic activity of morphine in mice in comparison with similar effects of three agonist-antagonist agents: buprenorphine, butorphanol and nalbuphine. We also examined the antagonistic action of these three drugs by evaluating the analgesia and mydriasis in animals pretreated with morphine.The analgesic effect was assayed using the hot plate method while the pupillary responses were measured with a binocular operating microscope.Morphine produced dose-dependent mydriasis and analgesia in mice. The morphine-type agent buprenorphine and two nalorphine-type agonistantagonists, butorphanol and nalbuphine, caused agonistic mydriatic and analgesic effects, usually less effective then morphine. Buprenorphine proved to have higher agonist activity than butorphanol and nalbuphine. The difference between butorphanol and nalbuphine was not statistically significant.A correlation between the mydriatic and the analgesic activity, known to exist among oploid derivatives with agonist activity only, was also demonstrated in the three investigated agonist-antagonist agents.Morphine-induced mydriasis and analgesia were reversed by all three agonist-antagonist drugs, but buprenorphine is a significantly weak antagonist in comparison with butorphanol and nalbuphine. An antagonistic property (antimydriatic and antianalgesic effects after pretreatment with morphine) of both nalorphine-type investigated drugs was not statistically significant, except for the antianalgesic effect of nalbuphine in doses 1 and 3 mg·kg−1 which was higher in comparison with butorphanol.

Tolerance to the mydriatic effect of buprenorphine, butorphanol, nalbuphine, and cyclorphan, and cross-tolerance to morphine in mice

An increase in the use of opioid derivatives in the treatment of pain syndrome in clinical practice, and especially in the treatment of cancer, has added impetus to the search for an agent which does not induce tolerance and cross-tolerance to other opiodis. The mydriatic effect of opioids in mice, the correlation between analgesia and mydriasis, and tolerance to the analgesic effect of morphine in mice were evaluated previously. In the present work, tolerance to the mydriatic effect of four agonist-antagonists and cross-tolerance to morphine were examined. Measurement of the pupillary diameter was performed using a binocular operating microscope. Tolerance and cross-tolerance to morphine were developed following a chronic use of buprenorphine, nalbuphine, and cyclorphan. After chronic injection of butorphanol, no tolerance or cross-tolerance to morphine was observed.

Comparison of visceral pain incidence during cesarean section performed under spinal or epidural anesthesia

The incidence of visceral pain during cesarean section performed under regional anesthesia was studied in 80 unpremedicated patients. They were divided in two similar groups concerning age, weight and height. Group 1 consisted of 40 patients submitted to cesarean section under spinal anesthesia, while in group 2 (40 patients) epidural anesthesia was used. Surgery was totally painless for all patients of group 1 patients, whereas in group 2 intraoperative analgesia was complete for 11, good in 18 and fair in 10 patients. One patient of group 2 required general anesthesia due to excrutiating pain during exteriorization of uterus despite a seemly adequate lebel of cutaneous analgesia of T 6 · The authors conclude that spinal anesthesia favorably compares with epidural anesthesia for cesarean section, because the incidence of visceral pain with the former was nill and because both techniques are equally safe for mothers and neonates

Sore throat incidence with the laryngeal mask: A comparison with orotracheal intubation

The incidence of sore throat was evaluated among 80 healthy (ASA 1 and 2) nonpremedicated adult patients undergoing general anesthesia for general, plastic, urologic, gynecologic, and orthopedic surgery. The patients were randomly allocated in two groups: group one (n=39) consisted of patients in whom the airway was maintained by a laryngeal mask, and in group 2 (n=40), orotracheal intubation was performed. Both groups were similar in age, gender, site of surgery, and time of airway cannulation. Intraperitoneal surgery of the upper abdomen, and insertion of a nasogastric tube were exclusion criteria. The severity of sore throat was graded by the patients themselves using a visual analogue 100 mm scale, varying from 0 (no sore throat) to 10 (extremely sore). The sore throat incidence, severity and duration were significantly lower in the laryngeal mask group in comparison with the endotracheal intubation group.