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Faiz SHR, Nader ND, Niknejadi S, Davari-Farid S, Hobika GG, Rahimzadeh P. J Pain Res. 2019;12:201–207. There were concerns over the potential inaccurate representation of data in the original Figure 3 on page 205 of the published article. The spline approach used in the original figure illustrated scores that do not exist through the interpolation of missing parameters between concrete assessment time points. Therefore, we, the authors, replaced the image with a time-to-event analysis (Kaplan-Meier) where the event was set for the request for an analgesic within the first 24 hours. The new figure presents cumulative hazards (probability) of requesting an analgesic medication over the first 24 hours after ilioinguinal nerve block versus transverse abdomens plane block. The time-to-event analysis by the Kaplan-Meier Log-Rank test revealed no difference in analgesic requirement between the two types of blocks (P=0.912). The correct Figure 3 is as follows. Figure 3 The probability of request for additional parenteral analgesic drugs is shown at any given time.Abbreviation: TAP, transversus abdominis plane.

Nowadays, there are various methods to manage pain after laparoscopic cholecystectomy. The aim of this study was to compare the effectof preemptive versus postoperative use of ultrasound-guided transversus abdominis plane (USG-TAP) block on pain relief after laparoscopic cholecystectomy. In this single-blinded randomized clinical trial, the patients who were candidates for laparoscopic cholecystectomy were randomly divided into the two groups (n = 38 per group). In the preemptive group (PG) after the induction of anesthesia and in the postoperative group (POG) after the end of surgery and before the extubation, bilateral ultrasound-guided transversus abdominis plane (TAP) block was performed on patients using 20 cc of ropivacaine 0.25%. Both groups received patient controlled IV analgesia (PCIA) containing Acetaminophen (20 mg/ml) plus ketorolac (0.6 mg/ml) as a standard postoperative analgesia and meperidine 20 mg q 4 h PRN for rescue analgesia. Using the numerical rating scales (NSR), the patients’ pain intensity was assessed at time of arrival to the PACU and in 2th, 4th, 8th, 12th, 24th h. Primary outcome of interest is NSR at rest and coughing in the PACU and in 2th, 4th, 8th, 12th, 24th h. Secondary outcomes of interests were the time to first post-surgical rescue analgesic and level of patients’ pain control satisfaction in the first 24 h. The USG-TAP block significantly decreased pain score in the POG compared to the PG, and also the pain was relieved at rest especially in 8 and 12 h (p value ≤ 0.05) after the surgery. Pain score after coughing during recovery at 2, 8 and 12 h after the operation were significantly decreased. (p value ≤ 0.05) The patient satisfaction scores in the POG were significantly higher in all times. There was a statistically significant difference between the two groups in terms of rate of postoperative nausea and vomiting (PONV), indicating that patients in the POG had significantly lower incidences of the PONV compared tothe PG. The time to first analgesic request was significantly shorterin the POG, which was statistically significant (p value = 0.089). There was no statistically significant difference between the two groups in terms of consumption of analgesics. The postoperative TAP block could offer better postoperative analgesia than preepmtive TAP block.

Back pain is reported to be the fifth most common reason for referral a patient to a physician and the most common disability in modern society. The present study aimed to evaluate the effects of calcitonin addition on epidural injection in patients with degenerative spinal canal stenosis in comparison with epidural triamcinolone injection.The clinical trial study was performed on 40 patients with degenerative spinal stenosis, referred to pain clinic of RasoulAkram Hospital in 2018, who were randomly divided into two intervention and control groups, including 20 individuals in each group. In the intervention group, 50 units of calcitonin were injected with 8 cc of ropivacaine 0.2% while 80 mg of triamcinolone with 8 cc of ropivacaine 0.2% was injected in the control group. Functional disability was evaluated based on the Oswestry Disability Index (ODI) and pain ratings were assessed using the Visual Analogue Scale (VAS).Pain at 4 and 8 weeks after the procedure was significantly different between the two groups. A significant difference in the patient disability index was observed between two groups at 8 and 12 weeks after the procedure. On the other hand, the rate of analgesic consumption at 4, 8 and 12 weeks after the procedure was significantly decreased in the calcitonin group (P0.001).Based on our results, injection of calcitonin into the epidural space can reduce the pain of the patients and their analgesic consumption compared to the group receiving steroids through the epidural space.

Introduction: Electrical storms and ventricular tachycardia are two life-threatening arrhythmias that are becoming more common. In developing ventricular arrhythmias, the sympathetic nervous system plays a vital role. Stellate ganglion (SG) block can be used in many situations as an important therapeutic target, like treating tachyarryhthmias and ventricular tachyarrhythmias. Case Presentation: The patient was a 53 years old woman with a history of implantable cardioverter defibrillator (ICD) insertion due to ventricular tachycardia. The patient complained of an awkward and unpleasant sensation when the ICD sensed the tachyarrhythmia and shocked her. Regarding the positive response to the previous SG block, with the goal of a longer duration of this effect, stellate ganglion radiofrequency was performed. Conclusions: Stellate ganglion radiofrequency shows a safe and long-term effect for patients with tachyarrhythmias and ICD who cannot tolerate episodes of ICD activation.

Background: Post-laparoscopic cholecystectomy (LC) pain control is still an issue postoperatively. Objectives: We investigated the effectiveness of the unilateral right-side ultrasound-guided erector spinae plane block (ESPB) on post-LC pain intensity and opioid consumption. Methods: This is a parallel-arm randomized control trial on 62 adult patients with an American Society of Anesthesiologists (ASA) physical status ≤ 2 who underwent LC. The patients were randomized into 2 groups (the block group [BG] and the control group [CG]; n = 31 per group). BG received a single-shot right-sided T7 ESPB with 20 mL of 0.2% ropivacaine at arrival time in the post-anesthesia care unit (PACU). CG) received no regional anesthesia. Both groups received patient-controlled intravenous fentanyl and rescue meperidine for analgesia. The primary outcome was the pain intensity determined using a Numerical Rating Scale (NRS) in the first 24 hours after surgery. Secondary outcomes included total fentanyl and meperidine consumption within 24 hours. Results: Median pain scores were significantly higher in CG at rest and with coughing up to 12 hours after surgery compared with BG. Pain scores were higher in CG with a cough at 24 hours compared with BG (median 1 [interquartile range (IQR) 1, 2] vs. 1 [1, 0]; P = 0.0005). Total fentanyl consumption and meperidine consumption within 24 hours were significantly lower in BG compared with CG (median 60 µg [IQR 60, 90] vs 250 µg [90, 300]; P < 0.0001 and median 20 µg [IQR 10, 20] vs 25 [20, 25]; P = 0.002, respectively). Conclusions: A single-shot, right-sided, unilateral ESPB decreases post-LC opioid consumption and pain.

Context: This systematic review and meta-analysis evaluated the effect of the intra-articular injection of platelet-rich plasma (PRP) and oxygen-ozone therapy and provided an evidence-based methodology to treat KOA. Method: Databases, including Cochrane Library, PubMed, and EMBASE, were searched. The retrieval period was before 2021. Two reviewers performed the process of screening and data extraction. Mean differences were calculated [95% confidence interval (CI)] with an inverse-variance method and fixed effect model. Meta-analysis was performed using the latest version of STATA version 16. Results: A total of 12 studies out of 769 articles were evaluated. The mean difference of visual analog scale score between ozone and control groups in the first month after injection was -0.02 (MD, -0.02; 95% CI: -0.32, 0.28; P < 0.05). Mean differences of WOMAC pain, stiffness, and physical function score between baseline and after PRP were -3.53 (MD: -3.53; 95% CI: -4.04, -3.02; P = 0.00), -0.60 (MD: -0.60; 95% CI: -4.0 - 0.864, -0.34; P = 0.00), and -5.96 (MD: -5.96; 95% CI: -7.83, -4.09; P = 0.00). Conclusions: Our results showed that to treat knee osteoarthritis, using PRP for a longer period of 6 - 12 months after the intervention shows better clinical results, while oxygen-ozone therapy has short-term results.

Background: Paravertebral blocks are one of the possible postoperative pain management modalities after laparotomy. Adjuvants to local anesthetics, including alpha agonists, have been shown to lead to better pain relief and increased duration of analgesia. Objectives: The aim of this study is to examine the effect of adding dexmedetomidine to bupivacaine for ultrasound-guided paravertebral blocks in laparotomy. Methods: In this double-blind, randomized controlled trial (RCT), we enrolled 42 patients scheduled for T6 to T8 thoracic paravertebral block (TPVB) for analgesia after laparotomy. The patients were randomly assigned into two groups of BD (bupivacaine 2.5 mg/mL 20 mL plus dexmedetomidine 100 µg) and B (bupivacaine 20 mL alone). Following surgery, intravenous fentanyl patient-controlled analgesia was initiated. The numerical rating scale (NRS) for pain, sedation score, total analgesic consumption, time to first analgesic requirement, side effects (such as nausea and vomiting), respiratory depression, and patients’ satisfaction during the first 48 hours of evaluation were compared in the two groups. Results: Pain scores and mean total analgesic consumption at the first 48 hours in the BD group were significantly lower than Group B (P = 0.03 and P < 0.001, respectively). The time of first analgesic request was significantly longer in BD group (P < 0.001). Sedation scores and side effects did not differ significantly between the two groups. Conclusions: Adding dexmedetomidine to bupivacaine for TPVB after laparotomy yielded better postoperative pain management without significant complications.

Background: Mastectomy is sometimes performed in transgender patients, which may damage the regional nerves such as the pectoral and intercostobrachial nerves, leading to postoperative pain. An ultrasound-guided nerve block can be used to track and block the nerves properly. Objectives: This study aimed to compare the ultrasound-guided type-II pectoral nerve block with the blind (conventional) intercostal nerve block (ICNB) for pain control after breast tissue reconstruction surgery in transgender patients. Methods: In the present single-blind randomized clinical trial, 47 patients were randomly divided into two groups: (A) Ultrasound-guided type-II pectoral nerve block (n = 23) and (B) blind intercostal nerve block (n = 24). After nerve block in both groups, pain intensity at 3, 6, 12, and 24 hours after surgery, upper limb paresthesia, frequency of nausea and vomiting, shortness of breath, hematoma, and the length of hospital stay were assessed. Results: Patients who received the ultrasound-guided type-II pectoral nerve block had a greater reduction in pain intensity (24 h after surgery), opioid use (24 h after surgery), nausea, vomiting, and hospital stay than those who received ICNB, whereas the recovery time did not differ between the study groups. Conclusions: The pectoral nerve block under ultrasound guidance, compared to the intercostal nerve block, in transgender patients can reduce the required dosage of opioids within 24 hours, pain intensity within 24 hours after surgery, the incidence of postoperative nausea, and vomiting, and the hospital stay of patients.

Introduction Laparoscopic gynecologic surgery is one of the most well-known procedures. Pneumoperitoneum with carbon dioxide insufflation can cause unfavorable hemodynamic effects due to catecholamine and vasopressin release. Aim To examine the effects of stellate ganglion block on hemodynamic response and postoperative pain. Material and methods In a prospective double blinded randomized parallel study we included 40 patients with ASA physical status I and II, aged between 18 and 50 years with a gynecologic problem candidate for laparoscopic surgery under general anesthesia. The patients were randomly divided into two groups. Fifteen minutes before anesthesia induction, the patients underwent ultrasound guided stellate ganglion block with 10 ml of lidocaine 1% and the control group underwent stellate ganglion block using 10 ml of distilled water as placebo. After induction of general anesthesia, systolic and diastolic blood pressure and heart rate were recorded, especially after blowing of CO2 gas, the position change, depletion of CO2, and tracheal extubation in recovery. The postoperative pain was calculated using the visual analogue scale (VAS) at three times (0, 30, and 24 h after surgery). Results Our results showed that mean systolic and diastolic blood pressure and heart rate did not show any significant difference at the measurement times (p > 0.05), and mean VAS of patients in the two groups was significantly different for the three measurement times except 24 h after surgery (p Conclusions Stellate ganglion block before laparoscopic gynecologic surgery has no significant effect on intraoperative and postoperative hemodynamic responses; however, it can decrease VAS in the early postoperative period.

This case report introduces a 43-year-old woman who presented with left knee pain due to knee osteoarthritis. She developed a long-lasting nerve block with ropivacaine, plus common peroneal nerve palsy and foot drop following a genicular nerve block. Key words: Ropivacaine, knee osteoarthritis, genicular nerve block, foot drop

Background: Post-arthroscopic shoulder surgery pain is severe enough to interfere with initial recovery and rehabilitation. Objectives: We aimed to evaluate the analgesic effects of postoperative ultrasound-guided suprascapular plus axillary nerve blocks superficial subepidermal axon bundles (SSAB) with interscalene block (ISB) in arthroscopic shoulder surgery. Methods: In this single-blind randomized, open-label clinical trial, 80 candidates of elective arthroscopic shoulder surgery were randomly allocated to receive either SSAB or ISB at a postoperative care unit. The severity of resting and changing position pain was measured using visual analogue scale (VAS) score at 4h, 8h, 12h, 16h, and 24h, postoperatively. Timing of first opioid request, 24h dose requirement, patients' satisfaction rate, and side effects were also recorded. All registered data were analyzed using SPSS software version 23 for Windows (SPSS, Chicago, IL). Results: Resting and changing position pain scores were comparable between SSAB and ISB groups in the most time intervals. At 12h, moving and resting pain was significantly lower in ISB than SSAB group, while moving pain was more severe in ISB group at 24h assessment. Patient satisfaction scores were comparable between the two groups except for 12h assessment. Time to first analgesic requirement and total dose of 24h opioid requirement were not significantly different between the two groups. Conclusions: Suprascapular plus axillary nerve block could be an effective and safe alternative for interscalene block for pain management after arthroscopic shoulder surgery.

Background: World Health Organization (WHO) declared that the outbreak of COVID-19 constituted a public health emergency of global concern Objectives: Owing to limited data on critically ill patients admitted to ICU, we aimed to describe the clinical characteristics and prognosis of these patients based on ventilatory variables and clinical features Methods: In this retrospective study, 45 critically ill patients with laboratory-confirmed COVID-19 who were admitted to Intensive Care Unit (ICU) wards of the hospital from April 8 to May 9, 2020, were enrolled Medical files of the patients were reviewed, and demographic and clinical characteristics, laboratory data, lung CT scan findings, causes of intubation, and outcomes of the patients were all collected Results: The median age of the patients was 67 years (range 22 to 91), 64% were men, and hypertension was the most common comorbidity History of close contact with previously confirmed patients was positive in 62 2% of the patients The mean time from symptom onset to hospital admission was 5 98 ± 2 93 days The most common symptoms at the onset of illness were dyspnea (95 6%), and gastrointestinal symptoms (22 2%) were rare The average length of the intubation was 4 84 ± 3 28 days The distribution of intubation causes in the deceased patients was significantly more than the recovered patients (P = 0 031) The mean score of lung CT involvement in deaths (370 26 ± 207 50) was significantly higher than the recovered patients (235 71 ± 81 21) (P = 0 042) Length of the intubation had a statistically direct correlation with respiratory rate (P = 0 03) Conclusions: Most of the critically ill patients admitted to ICU were older men and had poor outcomes with a high mortality rate Furthermore, the score of chest CT involvement and respiratory rate are important prognostic factors in determining the severity of the illness, requiring ventilatory support, and outcome © 2020, Author(s)

Background: There are various protocols for pain management after anterior cruciate ligament (ACL) reconstruction surgery. Objective: This study aimed to compare two blocking protocols, including femoral nerve block (FNB) and infrapatellar nerve block (IPNB) in terms of pain severity, patient satisfaction, and muscle force preservation. Materials and Methods: This single-blind clinical trial study investigated the patients who underwent elective knee arthroscopic ACL surgery randomly either by ultrasound-guided FNB or IPNB. Subsequently, the patients were evaluated 1, 3, 6, 12, and 24 h following NB for pain severity, patient satisfaction level, and muscle force. Results: The pain score (both at rest and in flexion) was significantly lower in the first three h after the intervention in the FNB group. Moreover, the mean score of the patients’ satisfaction in the first hours was significantly higher in the FNB group after the procedure. Additionally, the IPNB group obtained a significantly faster mean time required for the first dose of opioid request. The mean dose of used opioids over 24 h was significantly lower in the FNB group. There was a significant difference between the groups in terms of the muscle strength score within 24 h; moreover, the FNB group obtained a significantly greater delay in muscle recovery. Conclusion: The FNB is associated with greater pain relief and satisfaction in patients who underwent arthroscopic ACL reconstruction surgery, compared to the IFNB technique. However, a further delay in the recovery of quadriceps muscle force is evident in the FNB group.

Background: Postoperative pain has many adverse effects and if not properly controlled, it can cause a wide range of problems. Objectives: The purpose of this study is to compare the results of using ketamine and apotel infusion pumps to control pain after posterior fusion surgery. Methods: In this clinical trial study, 72 patients hospitalized for posterior spine fusion surgery were randomly assigned into two groups, including ketamine infusion pumps (ketamin group) and apotel infusion pumps (apotel group). In the ketamin group, 0.2 mg/kg/h of ketamine was infused to by a pain pump with normal saline to 100 cc. In the apotel group, apotel was used instead of ketamine. The rate of pain was evaluated in recovery, and at 6, 12, 18, 24, and 48 hours after the surgery, based on VAS criteria. The rate of sedation was recorded based on Ramsy score. Results: There was no significant difference between age, sex, BMI, underlying diseases, and smoking in patients with posterior spinal fusion surgery between the groups. Postoperative pain score was significantly lower in the patients with posterior fusion surgery at 6, 12, 18, 24, and 48 hours in the ketamin group compared to the apotel group (P < 0.001). Patients’ satisfaction with the analgesia was significantly higher in the patients at 24 hours (P = 0.001) and 48 hours (P = 0.04) in the ketamine group compared to the apotel. With regards to the Ramsy scores of the patients with posterior fusion surgery, there was no significant difference between the groups (P = 0.16). Conclusions: The use of a ketamine infusion pump can be more effective than an apotel infusion pump to control pain after posterior fusion surgery.

Background: Knowledge about clinical features of critically ill patients with COVID-19 still lacks adequate information up to now. Objectives: We aimed to describe and compare the epidemiological and clinical characteristics of critically ill patients with COVID-19 in Rasoul Akram Hospital. Methods: In this case series, 70 critically ill patients with COVID-19 admitted in ICU wards of Rasoul Akram Hospital, Tehran, Iran, from 29 February to 25 April 2020 were enrolled. Demographic and clinical characteristics, laboratory data, and outcomes of the patients were all collected and compared between deceased and recovered patients. Results: Fifty-six cases had died of COVID-19, and 14 patients had fully recovered and discharged. The median age of the patients was 68 years old, ranging from 22 to 91 years, 66% were men, 80% had one or more comorbidities, and hypertension was the most common comorbidities (45% of deceased cases). The most common signs and symptoms at the onset of illness were SPO2 depression (92%) and dyspnea (90%). Dyspnea was significantly more common in deceased patients (95%) than recovered patients (70%) (P = 0.048). Most patients had lymphopenia (80%). The number of patients who needed mechanical ventilation in the deceased patients was 53 (95%), which was significantly more than the recovered patients (10 [70%]) (P = 0.048). Conclusions: The mortality rate of critically ill patients with COVID-19 is very high, and the patients with dyspnea and required mechanical ventilation are at higher risk for death.

Background: In previous clinical trials and a small number of studies, the fractional injection of anesthetics led to reduced physiological complications and hemodynamic stability and increased duration of anesthesia. Objectives: The present study intended to compare the effect of fractionated and bolus dose injection of bupivacaine and fentanyl on spinal anesthesia for lower limb fracture surgeries. Methods: In this randomized, double-blind clinical trial, 70 patients with lower limb fractures were divided into groups of bolus spinal anesthesia (Group A) and fractional spinal anesthesia (Group B). Group A received a bolus dose of 25 μg fentanyl plus 15 mg bupivacaine 0.5% intrathecally at a rate of 0.2 mL/sec and were laid down in supine position after 45 seconds. In Group B, a half dose of the mixture, i.e., 25 μg fentanyl plus 15 mg bupivacaine 0.5% mixture, was injected intrathecally, and then, the other half was injected after 45 seconds while the needle was still in place. Afterward, the patients were immediately laid down in the supine position. Hemodynamic changes in the sensory and motor blockage parameters were recorded in both groups. Results: The motor blockage onset time was shorter in Group B compared to Group A (P = 0.026). Moreover, the sensory blockage duration was longer (P = 0.035), and the highest level of sensory blockage was lower (P = 0.008) in Group B compared to Group A. Conclusions: Fractional spinal anesthesia led to a longer duration and more favorable levels of sensory blockage compared to the bolus method. In addition, hemodynamic changes and complications occurred less frequently following this procedure.

Poupak Rahimzadeh,1 Farnad Imani,1 Nahid Nafissi,2 Behzad Ebrahimi,3 Seyed Hamid Reza Faiz1 1Pain Research Center, Iran University of Medical Sciences, Tehran, Iran; 2Department of Surgery, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran; 3Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran Background: The incidence of menopausal symptoms, including hot flashes and sleep disturbance, caused by drug treatment is a common problem in breast cancer survivors. Considering the limitations of hormone therapy in such patients, several studies have been conducted to find alternative methods. The aim of this study was to investigate and compare the effectiveness of stellate ganglion block (SGB) with that of paroxetine, which was approved by the US Food and Drug Administration (FDA) as a medicine for the treatment of hot flashes and ensuing sleep disturbance. Patients and methods: A total of 40 patients survived from breast cancer and complaining of these symptoms were equally assigned to two groups of 20 each. In the study group, SGB was performed successfully under sonography guidance using 10 mL of 0.5% bupivacaine, and in the control group (paroxetine), the daily administration of 7.5 mg of paroxetine was conducted for 6 weeks. The frequency and severity of hot flash attacks and sleep quality of patients were evaluated prior to the intervention and after 2, 4 and 6 weeks. The incidence of adverse events during treatment or follow-up was recorded. Results: A significant decrease in hot flash score and sleep disturbance index (SDI) was observed in both groups. Comparison of the results showed no noticeable difference between the two groups. Two participants in the control group had discontinued medication due to gastrointestinal symptoms, and only one case of mild headache was reported in the study group. Conclusion: SGB is as much effective as paroxetine in controlling hot flashes and sleep disturbances in breast cancer survivors and is associated with few complications. Keywords: paroxetine, breast cancer, hot flashes, stellate ganglion block, ultrasound guidance

Poupak Rahimzadeh,1 Farnad Imani,1 Mohammad Ghahremani,1 Seyed Hamid Reza Faiz2 1Pain Research Center, Iran University of Medical Sciences, Tehran, Iran; 2Anesthesiology Department, Iran University of Medical Sciences, Tehran, Iran Background: Intervertebral disc herniation with the pressure on the surrounding neural structures is one of the most important causes of chronic low back pain, which sometimes leads to open surgery. Reducing the pressure inside the disc with intradiscal intervention such as laser irradiation or ozone injection is a minimally invasive method and an alternative to surgery with satisfactory results. These two methods were compared with each other in this research. Patients and methods: In this clinical trial, 40 patients with back pain radiating to lower limb due to lumbar intervertebral disc herniation were selected. These patients were randomly divided into two equal groups for percutaneous intradiscal intervention. The Laser Disc Decompression Group (LDG) (n=20) was exposed to 1500 J of laser irradiation into the disc center. In the Ozone Injection Group (OZG) patients (n=20), 6 mL of ozone 30 μg/mL was injected into the center of the disc. Considering the level of neural root involvement, both groups received 20 mg of triamcinolone injection via transforaminal epidural. Patients were followed up for 12 months regarding score on visual analogue scale and life performance improvement based on Oswestry Disability Index (ODI) and satisfaction level. Results: According to the results, no difference was found between the two groups for ODI variable before intervention, whereas OZG showed better ODI scores in the measured time intervals. In LDG, only a significant difference in terms of ODI score was found between the times of before surgery and the first month. Conclusion: Intradiscal ozone injection could be an effective and cost-effective method for treatment of patients with discogenic back pain. Keywords: low back pain, laser disc decompression, ozone injection, visual analogue scale, Oswestry Disability Index

Background Spinal block is a common procedure for lower limbs surgery. Fentanyl, a synthetic opioid and dexmedetomidine, a selective α2 agonist have been used as adjuvants in spinal anesthesia to prolong intraoperative and postoperative analgesia. The aim of current study is to compare the efficacy of dexmedetomidine and fentanyl added to intrathecal bupivacaine in orthopedic procedures in lower limbs. Methods In this randomized clinical trial, 90 patients undergoing elective lower limb surgeries were randomly allocated to three groups. Via intrathecal approach, the patients received 2.5 ml hyperbaric bupivacaine 0.5% plus 5 micrograms dexmedetomidine (BD group), 25 micrograms fentanyl (BF group) or 0.5 ml normal saline (BN group), respectively. Time to reach the complete motor block, the highest sensory level, regression from block, analgesic request and duration of the drug effect, hemodynamic changes and side effects were compared between the groups. Results There was no significant difference between the groups regrading time to reach complete motor block, but time to reach the highest sensory level was shorter in group BD than group BF (6.28 ± 1.75 vs. 7.17 ± 1.45, p = 0.03). Group BD had significantly lower mean of NRS 6 h after operation (1.90 ± 0.84 vs. 6.16 ± 1.44 vs. 6.30 ± 1.17, p

Seyed Hamid Reza Faiz,1 Seyed Alireza Seyed Siamdoust,2 Poupak Rahimzadeh,1 Leila Houshmand3 1Pain Research Center, Iran University of Medical Sciences, Tehran, Iran; 2Anesthesiology Department, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran; 3Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran Backgrounds and objective: Some studies have shown that deeper anesthesia is more effective on postoperative analgesia and reduces the need for sedative drugs. This study sought to ­investigate the effect of depth of anesthesia on postoperative pain in laparoscopic cholecystectomy. Materials and methods: In this double-blind clinical trial, 60 patients undergoing laparoscopic cholecystectomy were randomly divided into two groups: low bispectral index (L-BIS=35–44) and high bispectral index (H-BIS=45–55). Anesthesia protocol was the same for both groups (propofol and remifentanil). The pain intensity (at rest and during cough) was evaluated based on the visual analog scale scores in recovery and at 8, 16 and 24hours after surgery. Results: The mean pain score was significantly lower in patients in the L-BIS group at all examined times at rest and during cough than that in the H-BIS group. The number of patients in need of additional sedative drug in the H-BIS group in recovery was significantly more than that in the L-BIS group (27 vs 18 patients, P=0.007). The incidence of nausea in the recovery room 8hours after the surgery was significantly less in the L-BIS group than that in the H-BIS group, while at 16 and 24hours, no case of nausea was reported in the two groups. Conclusion: Given the results of this study, it seems that general anesthesia with propofol and remifentanil with L-BIS causes less need for additional analgesic drug and less nausea and vomiting compared to anesthesia with H-BIS. Keywords: BIS, postoperative pain, depth of anesthesia, laparoscopic cholecystectomy

Background: Administration of steroids in the lumbar transforaminal block for lumbar radicular pain is considered one of the preferred treatment methods though it is associated with some complications. Objectives: The effects and side effects of triamcinolone and dexmedetomidine in the lumbar transforaminal block were investigated in the present study. Methods: In this study, 30 patients, aged 40-70 years, suffering from lumbar radicular pain arising from the lumbar disc protrusion were equally divided into two groups of triamcinolone (T) and dexmedetomidine (D). They all underwent lumbar transforaminal blocks. An injection solution of triamcinolone (20 mg) plus ropivacaine (0.2) and another one containing dexmedetomidine (50 µg) plus ropivacaine (0.2) were administered in the triamcinolone and dexmedetomidine groups, respectively. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Straight Leg Raise (SLR or lasegue’s test), and Fasting Blood Sugar (FBS) were measured at 0, 2 weeks, 1, 3, and 6 months post-procedure. The levels of calcium, magnesium, and vitamin D, as well as potential complications, were also evaluated. Results: Significant differences were found in the VAS and ODI during the measurement times within each group. The VAS and ODI were remarkably different between the dexmedetomidine group and the triamcinolone group. In addition, there were considerable differences in the increased FBS and reduced calcium and vitamin D levels in the triamcinolone group from changes in the dexmedetomidine group. Conclusions: The lumbar transforaminal block with triamcinolone or dexmedetomidine attenuates the lumbar radicular pain. Further, dexmedetomidine exerts a more potent pain relief effect than triamcinolone. © 2019, Author(s).

Background and aims Intra-articular dextrose and somatotropin injection, as an alternative therapy has been found beneficial for knee osteoarthritis (OA). Recent studies suggested ozone as a candidate based on analgesic, anti-inflammatory and anti-oxidant for these diseases. the aim of this study is investigation of the efficacy of adding ozone to dextrose and somatotropin in patients with knee OA and assess the effects of this modality on pain, joint stiffness and physical activity. Methods Sixty patients who were suffering from knee OA randomly assigned to two groups. In the first group (DS), intra-articular knee injection was 10 ml of 50% dextrose and 4IU somatotropin. In the second group (DSP) a mixture of 10 ml of 50% dextrose, 4IU somatotropin and 10 ml of ozone 25 mcg was injected. Then, during the 3rd, 5th and 16th following week’s participants were examined by Western Ontario and McMaster universities osteoarthritis index (WOMAC Score). Results The mean WOMAC score of patients in the DS group has decreased significantly from 64.9±10.7 at the beginning of the study to 49.2±9.0 at sixteen weeks after that (P Conclusions Adding ozone to dextrose, somatotropin for intra-articular knee injection is more effective for knee osteoarthritis by improving pain, stiffness and functioning of the joint.

Background and aims Paracetamol and non-steroidal anti-inflammatory drugs (e.g. ketorolac) can be considered for mild to moderate post-caesarean pain. as a selective α-2 agonist adrenergic receptor, dexmedetomidine has analgesic and sedative effects without causing respiratory depression. This study aimed to evaluate the effects of adding dexmedetomidine to paracetamol or ketorolac on post-caesarean pain and the associated complications thereof. Methods 60 pregnant women who were candidates for caesarean section with spinal anesthesia were randomly assigned to either of two groups of 30 patients. For post-operative pain management, an intravenous patient-controlled analgesia (PCA) device was used for 24 hours. Dexmedetomidine (3 µg kg-1) was added to paracetamol (35 mg kg-1) in the group DP and to ketorolac (1 mg kg-1) in the group DK. Visual analog scale (VAS), Ramsay sedation scale, hemodynamic changes, rescue analgesic (meperidine) consumption, patient satisfaction, and possible complications were recorded at 6, 12, and 24, hours after surgery, and compared afterward. Results The pain score was significantly lower in the DK group than in the DP group (P Conclusions The addition of dexmedetomidine to ketorolac, compared with its addition to paracetamol, causes further reduction in the post-operative pain score and provides more satisfaction.

Background Acute postoperative pain causes severe discomfort in patients accompanied by hemodynamic and metabolic instability. Objectives The aim of this study was to evaluate the effects of nitroglycerin addition on the infusion of intravenous analgesia pump in patients with lower limb orthopedic surgery. Methods This study was a double-blind clinical trial conducted on 75 patients with lower limb fracture. Patients were randomly assigned to receive three regimens for postoperative pain control via intravenous analgesia pump, including group A (fentanyl 10mc/kg + 10 mL distilled water), B (fentanyl 10 mc/kg + nitroglycerin 500 mc), and C (fentanyl 10 mc/kg + nitroglycerin 1000 mc). The patients at the beginning of recovery and prior to putting the pain pump at the time of 4, 8, 12, 24, and 48 hours, were assessed with visual analogue scale (VAS) to measure pain and Ramsay scale to measure sedation. Results The results showed that weight, height, and gender distribution were not significantly different in the three groups. The HR, MAP, and VAS mean scores showed a significant difference for intragroup and intergroup differences in the three groups at many times. Conclusions Low dose nitroglycerine, as an adjuvant drug, can be added to intravenous patient-controlled analgesia pump in patients undergoing surgery for better analgesic purposes in patients without underlining disease.

Background Acupuncture has been used for more than two thousand years as part of traditional Chinese medicine. Objectives This randomized prospective clinical trial aimed to compare the effect of acupuncture on K1 (Yongquan) and DU26 (Renghong) with acupuncture on K1 (Yongquan) and DU25 (Suliao), with sham acupuncture on the recovery time of general anesthesia. Methods The patients (51) were randomly assigned to three groups: (A) acupuncture on K1 and DU26, (B) acupuncture on K1 and DU25, and (C) sham acupuncture. In each group, at the end of surgery acupuncture was performed accordingly for twenty minutes and the Bispectral Index (BIS) values at end of surgery, 5th minute, 10th minute, 15th minute and 20th minute as well as time of extubation and time of eye opening after the end of surgery were evaluated. Results BIS study at 5th minute, 10th minute and 15th minute after the end of surgery in the groups revealed a significant difference between sham acupuncture group and both A and B acupuncture groups, which was higher in groups A and B in comparison with sham acupuncture group. Time of opening eyes and time of extubation after the end of surgery between group A and sham acupuncture group differed significantly, which was earlier in group A. There was no significant difference between group B and sham acupuncture group in terms of eye opening and extubation time. Conclusions Acupuncture on K1 and DU26 accelerates restoring of consciousness and shortens of eye opening and extubation after general anesthesia, but on K1 and DU25 only speeds up retrieving of consciousness without significant effect on time of eye opening or extubation after general anesthesia.

Background: Perioperative glycemic control is an important factor in the clinical management of a patient with diabetes mellitus under surgery. Poorly controlled long-term hyperglycemia not only predisposes individuals to systemic complications of diabetes mellitus and cardiovascular morbidity but also increases the risk of anesthesia and weakens the outcome of the surgery. Given the importance of the issue and the limited studies on glucose control using insulin glargine during surgery, we aimed to investigate the effects of glargine on glucose control in patients with diabetes mellitus during vitrectomy surgery. Methods: This randomized, double-blind trial was conducted in two groups of 35 patients with diabetes mellitus under treatment with insulin. In the control group, the patients received regular insulin based on the blood glucose and the sliding scale, and in the intervention group, they received insulin glargine (0.3 unit/kg) before surgery. From the start of the operation up to 3 hours of the surgery blood glucose of the patients was measured every 45 minutes and once 6 hours after the operation, and if needed, the regular insulin was injected. Data were analyzed using SPSS 16. Frequency, percentage, mean, and standard deviation (SD) were used to describe the data. To compare the quantitative variables, the independent t-test or U-Mann-Whitney test was used. For comparison of the qualitative variables, Chi-square test or Fischer's exact test and repeated measure ANOVA was employed. The significance level (P-value) was considered as p

Background Nowadays, ultrasound is increasingly used with a great accuracy in performing nerve blocks for facet joint disease. Objectives To measure sonoanatomic characteristics for the facet joints of lumbar vertebras in patients with facetogenic pain and healthy volunteers. Study design Cross-sectional, observational study. Setting University-affiliated Specialty Clinic for Pain Management. Patients Twenty patients with facet joint disease (FJD) and 40 healthy volunteers (HVGs) were matched for age and sex, height, and weight. Patients with FJD were referred with complaints of pain in the left lumbar facet joints that twice responded favorably to ultrasound guided medial branch blocks. Intervention Medial branch blocks. Measurement The interfacet joint distance (IFJD) between the third, the fourth, and the fifth lumbar vertebras and their depth from the level of skin (DFS) were measured bilaterally, using a high-resolution ultrasound in both groups. Results Thirty-one men and 29 women with average age of 41.5±9.5 years were enrolled. The IFJD for L3-L4 was 31.5±4.0 mm on the left side and 31.8±4.0 mm on the right side. The IFJD for L4-L5 was 31.3±4.4 mm on the left side and 31.5±4.0 mm on the right side. The IFJD was uniformly 2.2 mm shorter in the FJD group than those in the HVG group ( P =.021). The measurements of DFS increased in lower vertebras (L3 P =.016), DFS measurements were similar in FJD and HVG groups. Limitations The diagnosis of facet joint disease was merely clinical and the total number of the patients was relatively small. Conclusion Interfacet distances of the lumbar vertebras are smaller in patients suffering from degenerative FJD compared with HVGs. Degenerative changes of intervertebral discs and partial reduction of space between 2 adjacent vertebras may contribute to this observation.

Seyed Hamid Reza Faiz,1 Nader D Nader,2 Soraya Niknejadi,1 Sina Davari-Farid,2 Geoffrey G Hobika,2 Poupak Rahimzadeh3 1Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran; 2Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA; 3Pain Research Center, Iran University of Medical Sciences, Tehran, Iran Objective: To compare the efficacy of ilioinguinal/iliohypogastric (IINB) nerve block to transversus abdominis plane (TAP) block in controlling incisional pain after open inguinal hernia repair. Patients and methods: This was a prospective randomized clinical trial of 90 patients who received either IINB (N=45) or TAP block (N=45) using 0.2% bupivacaine 15 mL under ultrasound (US) guidance based on a random assignment in the postanesthesia care unit after having an open repair of inguinal hernia. Numeric Rating Scale (NRS) scores were recorded immediately following, 4, 8, 12, and 24 hours after completion of the block. NRS scores at rest and during movement were recorded 24, 36, and 48 hours after surgery. Analgesic satisfaction level was also evaluated by a Likert-based patient questionnaire. Results: NRS scores were lower in the IINB group compared to the TAP block group both at rest and during movement. The difference in dynamic pain scores was statistically significant (P=0.017). In addition, analgesic satisfaction was significantly greater in the IINB group than the TAP block group (mean score 2.43 vs 1.84, P=0.001). Postoperative opioid requirements did not differ between the two groups. Conclusion: This study demonstrated that compared to TAP block, local blockade of ilioinguinal and iliohypogastric nerves provides better pain control after open repair of inguinal hernia when both blocks were administered under US guidance. Greater satisfaction scores also reflected superior analgesia in patients receiving IINB. Keywords: US-guided nerve block, transversus abdominis plane, ilioinguinal, iliohypogastric nerve, inguinal hernia surgery

Background: Postoperative pain is a major complication in patients undergoing eye surgery. N-methyl-D-aspartate (NMDA) receptor antagonists are widely used to manage postoperative pains. Dextromethorphan, as an NMDA antagonist, is commonly used as an oral drug. Objectives: This study was conducted to evaluate the effect of Dextromethorphan on post-operation pain and sedative effect in comparison to placebo. Methods: A double-blinded, placebo-controlled, randomized clinical trial, upon 60 patients undergoing vitrectomy surgery was done. Thirty patients received 30 mg oral Dextromethorphan before the operation, and 30 patients received a placebo. Post-operation pain and sedation were evaluated after zero, one, two, and six hours. Results: Post-operation pain was significantly lower in patients who received Dextromethorphan at zero, one, and two hours after operation (P < 0.001); however, not at six hours after operation (P = 0.11). Sedative effect was higher in the Dextromethorphan group at zero (P = 0.03) and one hour (P = 0.01) after operation. Conclusions: Prescribing oral Dextromethorphan before a vitrectomy surgery could reduce postoperative pain. It also has postoperative sedation effects.

Background: Paracetamol and non-steroidal anti-inflammatory drugs (e.g. ketorolac) can be considered for mild to moderate post-caesarean pain. As a selective α-2 agonist adrenergic receptor, dexmedetomidine has analgesic and sedative effects without causing respiratory depression. Objectives: This study aimed to evaluate the effects of adding dexmedetomidine to paracetamol or ketorolac on post-caesarean pain and the associated complications thereof. Methods: Sixty pregnant women, who were candidates for caesarean section with spinal anesthesia, were randomly assigned to either of two groups of 30 patients. For post-operative pain management, an intravenous patient-controlled analgesia (PCA) device was used for 24 hours. Dexmedetomidine (3 µg kg-1) was added to paracetamol (35 mg kg-1) in the group DP and to ketorolac (1 mg kg-1) in the group DK. Visual analog scale (VAS), Ramsay sedation scale, hemodynamic changes, rescue analgesic (meperidine) consumption, patient satisfaction, and possible complications were recorded at 6, 12, and 24, hours after surgery, and compared afterward. Results: The pain score was significantly lower in the DK group than in the DP group (P < 0.05). The hemodynamics and sedation scale were similar in both groups. The total meperidine consumption was higher in the DP group, but it was not significantly different. Maternal satisfaction was greater in the DK group (P < 0.05). Concerning complications, the two groups did not show statistically significant differences (P = 0.4). Conclusions: The addition of dexmedetomidine to ketorolac, compared with its addition to paracetamol, causes further reduction in the post-operative pain score and provides more satisfaction.

Background: Postoperative pain is a common complication after Cesarean Section (CS) and its management is essential to prevent adverse effects of pain. Various methods are used to control pain after CS. Regional anesthesia using Transversalis Fascia Plane (TFP) and Transversus Abdominis Plane (TAP) block is shown to reduce pain after abdominal surgery. Objectives: This study aimed at evaluating the efficacy of these two methods in controlling pain after CS. Methods: In this randomized clinical trial, 56 patients undergoing elective CS under spinal anesthesia were randomly allocated to receive TFP or TAP block after surgery with ultrasound guidance. The pain severity using Visual Analogue Scale (VAS) at rest and during coughing at 0, 2, 4, 6, 12, 24, and 36 hours after surgery, time to first analgesic request, and dosage of analgesic use and complications were compared between groups. Results: There were no significant differences between groups in pain severity at rest or coughing at0, 2, 4, 6, 12, 24 and 36 hours, postoperatively. There was no considerable nausea and vomiting between groups (14.3% vs. 10.7%, P = 0.68), and time to the first analgesia (100.00 ± 69.28 versus 123.12 ± 50.19 minutes, P = 0.47) and total analgesic use (33.33 ± 14.43 vs. 25.00 ± 15.81 mg, P = 0.57) were comparable between groups. There were no complications in any of the groups. Patients in both groups were mostly satisfied for pain control after surgery (good to perfect, 89.3% versus 82.1%, P = 0.7). Conclusions: Ultrasound-guided TFP provided pain control the same as TAP block after CS with a comparable decreased need of analgesics.

[This corrects the article on p. 249 in vol. 46, PMID: 30140529.].

Background: Rapid placement of a reliable airway is the most important task in anesthesia practice. Airway management is a critical skill to provide safe anesthesia since morbidity. In addition, mortality due to anesthesia could be linked to difficulty or failure in airway management. In this study, intubation success was compared between two methods, AirQ-ILA and LMAfastrach, among candidates for elective surgery under general anesthesia. Methods: In this clinical trial, patients, who were candidates for elective surgery under general anesthesia at Firoozgar and Rasoul Akram Hospitals, were randomly divided into LMAfastrach and AirQ-ILA groups. Heart rate before and after induction and intubation, diastolic blood pressure, systolic blood pressure, duration of device insertion, intubation time, number of attempts until successful device insertion and trachea intubation, and success or failure in the insertion of the device and the tube were recorded; as for statistical analysis, SPSS version 21 was considered. Results: In comparison with the LMAfastrach group, the device insertion time and intubation time were significantly longer in the AirQ-ILA group (P < 0.05). However, the groups showed no significant difference regarding the number of device and tube insertion attempts (P > 0.05). Moreover, no significant difference was observed in the success of device insertion and intubation in either LMAfastrach or AirQ-ILA group (P > 0.05). Conclusions: The LMAfastrach and AirQ-ILA methods were not significantly different regarding the success of airway instrument application and intubation, while the device insertion time and intubation time were significantly longer in the AirQ-ILA group in comparison with the LMAfastrach group.

Objective A variety of methods, including neuraxial and regional blocks, have been used to manage post-mastectomy pain. This study evaluates the effect of serratus anterior plane block on acute pain after mastectomy. Methods A total of 60 patients who were candidates for mastectomy under general anaesthesia were divided in this trial into two groups. After entering the recovery room, the first-experimental-group (SAB) underwent the ultrasound-guided serratus anterior block, but the second-control-group (CTL) received no block intervention. An intravenous patient-controlled analgesia (PCA) device was used to deliver fentanyl in both groups. Using the Visual Analog Scale (VAS), the patients' pain was assessed at intervals of 1, 6, 12 and 24 hours after entering the recovery room. Intravenous acetaminophen was administered as a rescue analgesic if the pain exceeded 3 on the VAS. A total amount of fentanyl consumed, the time to first PCA request, a total amount of acetaminophen consumption and possible adverse effects were evaluated. Results The pain scores assessed at the time intervals were not significantly different between the two groups (p>0.5). The total consumption of fentanyl was significantly lower in the SAB group than in the CTL group (p=0.0001). Duration of the time to first PCA request was remarkably longer in the SAB group than in the CTL group (p=0.0001). The total amount of acetaminophen consumed was notably higher in the CTL group than in the SAB group (p=0.001). None of the patients experienced side effects. Conclusion Undertaking serratus anterior block following mastectomy can reduce pain scores and lower opioid usage.

Poupak Rahimzadeh,1 Farnad Imani,1 Seyed Hamid Reza Faiz,2 Saeed Reza Entezary,3 Mahnaz Narimani Zamanabadi,4 Mahmoud Reza Alebouyeh3 1Pain Research Center, Iran University of Medical Sciences, Tehran, Iran; 2Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran; 3Anesthesia Department, Iran University of Medical Sciences, Tehran, Iran; 4Pain Fellowship, Iran University of Medical Sciences, Tehran, Iran Introduction: Osteoarthritis (OA) is a chronic joint disease that usually occurs in older people and leads to pain and disabilities. OA treatment ranges from drug therapy to surgery. Drug and rehabilitation therapy are preferred over surgery, and, especially, there is a tendency toward compounds causing regenerative changes in the knee joint. In the present study, the effects of platelet-rich plasma (PRP) injection and prolotherapy (PRL) were examined on the level of pain and function of the knee joint in patients with OA.Methodology: After fulfilling the inclusion criteria and signing the informed consent form, 42 patients with knee OA were scheduled for intra-articular injection in the present randomized, double-blind, clinical trial. Following admission to the operating pain room, the condition of the patient’s knee was evaluated first via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and, then, ultrasound-guided knee injection was done. Accordingly, patients in the PRP therapy group received 7 mL PRP solution and those in the PRL group received 7mL 25% dextrose. Using the WOMAC, levels of pain and knee function were evaluated and recorded for each patient immediately prior to the first injection as well as at 1 month (immediately prior to the second injection), 2 months (a month after the second injection), and 6 months later. Data collected were analyzed using the SPSS v.20.Results: During the first and second months, a rapid decrease in the overall WOMAC score was observed in both groups. The overall WOMAC score increased at the sixth month, but was lower than the overall WOMAC score in the first month. Statistical analysis indicated that the overall WOMAC score significantly decreased in both groups of patients over 6 months.Conclusion: Results of the present study suggested a significant decrease in the overall WOMAC score of patients who undergo either PRP therapy or PRL. This positive change in the overall WOMAC score led to an improvement in the quality of life of patients with knee OA shortly after the first injection. PRP injection is more effective than PRL in the treatment of knee OA. Keywords: knee osteoarthritis, platelet-rich plasma, prolotherapy, ultrasound

Seyed Hamid Reza Faiz,1 Mahmoud Reza Alebouyeh,2 Pooya Derakhshan,2 Farnad Imani,3 Poupak Rahimzadeh,3 Maryam Ghaderi Ashtiani2 1Endometriosis Research Center, Iran University of Medical Sciences, Tehran, Iran; 2Anesthesia Department, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran; 3Pain Research Center, Iran University of Medical Sciences, Tehran, Iran Background: Due to the importance of pain control after abdominal surgery, several methods such as transversus abdominis plane (TAP) block are used to reduce the pain after surgery. TAP blocks can be performed using various ultrasound-guided approaches. Two important approaches to do this are ultrasound-guided lateral and posterior approaches. This study aimed to compare the two approaches of ultrasound-guided lateral and posterior TAP blocks to control pain after cesarean section. Materials and methods: In this double-blind clinical trial study, 76 patients scheduled for elective cesarean section were selected and randomly divided into two groups of 38 and underwent spinal anesthesia. For pain management after the surgery, one group underwent lateral TAP block and the other group underwent posterior TAP block using 20cc of ropivacaine 0.2% on both sides. Pain intensity was evaluated based on Numerical Analog Scale (NAS) at rest and when coughing, 2, 4, 6, 12, 24 and 36 hours after surgery. Results: The pain at rest in the posterior group at all hours post surgery was lower than the lateral group, especially at 6, 12 and 24 hours after the surgery and the difference was statistically significant (p=0.03, p

Background and Objective: A local nerve block is used to relieve pain and improve the positioning of patients during spinal anesthesia. This study attempted to compare femoral nerve block (FNB) versus fascia iliaca compartment (FIC) block. Methods: In this clinical trial, a total of 68 patients undergoing surgery for femoral shaft fractures were divided randomly to 2 groups of FNB and FIC. The patients’ pain was recorded by the visual analogue scale (VAS) before and during administration of femoral nerve block. Satisfaction of positioning for spinal anesthesia and duration of the procedure were also recorded in the 2 groups. Results: During the nerve block, the pain score of FIC was significantly lower than that of the FNB group (2.5±0.6, 3.6±0.8 and P = 0.001). During the administration of spinal anesthesia, the mean pain in the FNB group was significantly lower than that of FIC (2.7 ± 1.1, 3.4 ± 0.6 and P = 0.001). The satisfaction of patients with positioning in the FNB group was reported to be excellent by 40.7% of patients, whereas none in the FIC group reported satisfaction. The completion time of sensory block was significantly lower in the FNB group than the FIC group (P = 0.001). Conclusions: The FNB seems to provide better analgesia during spinal anesthesia for the patient, even though the administration of FIC tends to be easier and less painful than the FNB. Shorter completion time of sensory and motor block in the FNB group could be indicative of the superiority of this method for providing the appropriate conditions for spinal anesthesia in an emergency setting

Background Peripheral nerve block is an accepted method in lower limb surgeries regarding its convenience and good tolerance by the patients. Quick performance and fast sensory and motor block are highly demanded in this method. The aim of the present study was to compare 2 different methods of sciatic and tibial-peroneal nerve block in lower limb surgeries in terms of block onset. Methods In this clinical trial, 52 candidates for elective lower limb surgery were randomly divided into 2 groups: sciatic nerve block before bifurcation (SG; n = 27) and separate tibial-peroneal nerve block (TPG; n = 25) under ultrasound plus nerve stimulator guidance. The mean duration of block performance, as well as complete sensory and motor block, was recorded and compared between the groups. Results The mean duration of complete sensory block in the SG and TPG groups was 35.4 ± 4.1 and 24.9 ± 4.2 minutes, respectively, which was significantly lower in the TPG group (P = 0.001). The mean duration of complete motor block in the SG and TPG groups was 63.3 ± 4.4 and 48.4 ± 4.6 minutes, respectively, which was significantly lower in the TPG group (P = 0.001). No nerve injuries, paresthesia, or other possible side effects were reported in patients. Conclusions According to the present study, it seems that TPG shows a faster sensory and motor block than SG.

Background: Management of low back pain after spinal surgeries is one of the most challenging problems in pain medicine. Transforaminal lumbar epidural steroid injection has been used with inconsistent response. Most patients require multiple and frequent injections due to high recurrence of back pain. Objective: To find out whether the addition of hyaluronidase to the epidural injectate affects the quality and duration of analgesia in patients with low back pain secondary to failed back surgery syndrome. Study Design: Prospective randomized trial. Methods: The study was registered in the Government Clinical Trial registry and the protocol was reviewed and approved by the institutional review board. After obtaining an informed consent, 25 patients with low back pain due to failed back syndrome were randomly assigned to receive a transforaminal epidural injection of hyaluronidase 1500 IU (HYL) or normal saline (NSL) to a mixture of bupivacaine 0.5% (1 mL) and triamcinolone 40mg (1 mL) in a doubleblind fashion. An interventional pain specialist using fluoroscopic guidance performed all epidural injections. The patients received a comprehensive neurological examination by a non-interventional pain specialist who was blinded to the treatment during their follow-up visits, scheduled one, 2, and 4 weeks after the intervention. Numerical pain scores, analgesic requirement, and satisfaction scores were recorded during every visit. Results: There was no difference in demographic data between the 2 groups. Pain scores and total analgesic requirement were significantly lower in the HYL group at 2 and 4 weeks after blockade (P < 0.01). Patient satisfaction was higher in the HYL group. Limitations: The study was limited by a relatively small sample size. Conclusion: We conclude that adding hyaluronidase to the epidural injectate was effective in the management of chronic low back pain in patients with failed back surgery syndrome demonstrated over a period of 4 weeks. Key words: Low back pain, lumbar epidural injection, steroid, hyalorunidase, bupivacaine

Background: Osteoarthritis is one of the most common diseases and the knee is the most commonly affected joint. Intra-articular prolotherapy is being utilized in acute and chronic pain management setting. This study was designed to compare the efficacy of three methods of intra-articular knee joint therapies with erythropoietin, dextrose, and pulsed radiofrequency. Materials and Methods: After approval by the Ethics Committee and explaining the therapeutic method to volunteers, 70 patients who were suffering from primary knee osteoarthrosis went through one of the treatment methods (erythropoietin, dextrose, and pulsed radiofrequency). The study was double-blind randomized clinical trial performed from December 2012 to July 2013. Patients′ pain level was assessed through the visual analog pain scale (VAS), and range of motion (ROM) was measured by goniometric method. Furthermore, patients′ satisfaction was assessed before and after different treatment methods in weeks 2, 4, and 12. For analysis, Chi-square, one-way ANOVA, and repeated measured ANOVA were utilized. Results: The demographic results among the three groups did not indicate any statistical difference. The mean VAS in erythropoietin group in the 2 nd , 4 th , and 12 th weeks was 3.15 ± 1.08, 3.15 ± 1.08, and 3.5 ± 1.23, respectively (P ≤ 0.005). Knee joint ROM in the erythropoietin group in the 2 nd , 4 th , and 12 th weeks was 124 ± 1.50, 124 ± 1.4, and 123 ± 1.53 respectively (P ≤ 0.005). Satisfaction score in the 12 th week in erythropoietin group was extremely satisfied 15%, satisfied 55%, and moderately satisfied 30%, (P = 0.005). No specific side-effects were observed. Conclusion: Intra-articular prolotherapy with erythropoietin was more effective in terms of pain level reduction and ROM improvement compared with dextrose and pulsed radiofrequency.

Background: Regional anesthesia is known to significantly impair thermoregulation and predispose patients to hypo thermia. We hypothesized that the addition of an intrathecal injection of magnesium sulfate (MgSO 4 ) to bupivacaine would improve perioperative shivering in female patients undergoing elective caesarean section. Methods: In a block-randomized, double-blinded, controlled trial 72 patients scheduled for elective caesarean section with spinal anesthesia were separated into two groups. In the treatment group, 2 ml of 0.5% bupivacaine plus 25 mg MgSO 4 (0.5 ml) were injected intrathecally, and in the control group 2 ml of 0.5% bupivacaine plus 0.5 ml normal saline were injected intrathecally. Core temperature was measured before and after drug injection at predetermined intervals. Sedation was graded using the Ramsay sedation scale. Results: No significant intergroup differences in appearance of shivering were seen immediately or at 5, 30, 40, 50, 60, and 90 min after block administration. However, at 10, 15, and 20 min post block, there was a significant difference in shivering. The group administered MgSO 4 showed lower shivering grades compared with the control group. Core temperature was significantly reduced in the MgSO 4 group compared to the normal saline group 30 min after blocking. Conclusions: Intrathecal injection of MgSO 4 improved perioperative shivering in female patients undergoing elective caesarean section. (Korean J Anesthesiol 2013; 65: 293-298)

Background The pes anserine bursa lies beneath the pes anserine tendon, which is the insertional tendon of the sartorius, gracilis, and semitendinosus muscles on the medial side of the tibia, but it can lie in different sites in the medial knee. Accurate diagnosis of the position of the bursa is critical for diagnostic and therapeutic goals. The aim of this study was to evaluate sonoanatomic variations of the pes anserine bursa in the medial knee. Methods One hundred seventy asymptomatic volunteers were enrolled in this study. Using ultrasound imaging (transverse approach, 7-13 MHz linear array probe) the sonoanatomic position of the pes anserine bursa and its relation to the pes anserine tendon were evaluated. Additionally, we evaluated the sonoanatomic variation of the saphenous nerve. Results The position of the pes anserine bursa was between the medial collateral ligament and the pes anserine tendons in 21.2%/18.8% (males/females) of subjects; between the pes anserine tendons and the tibia in 67.1%/64.7% (m/f); and among the pes anserine tendons in 8.2%/12.9% (m/f). No significant differences in the position of the bursa existed between males and females. The saphenous nerve was found within the pes anserine tendons in 77.6%/74.1% (m/f) of subjects, but outside the pes anserine tendons in 18.8%/15.3% (m/f). Visibility of sonoanatomic structures was not related to either gender or BMI. Conclusions Ultrasound provides very accurate information about variations in the pes anserine bursa and the saphenous nerve. This suggests that our proposed ultrasound method can be a reliable guide to facilitate approaches to the medial knee for diagnostic and therapeutic objectives.

OBJECTIVE To compare the analgesic effects of femoral nerve block (FNB) and adductor canal block (ACB) after arthroscopic knee surgery. METHODS This was a prospective randomised clinical trial that enrolled 92 patients undergoing arthroscopic knee surgery. Ultrasound-guided FNB or ACB was performed immediately after surgery for pain relief. Visual analogue scale (VAS) scores and modified sedation-agitation scale (SAS) were recorded and analysed immediately following block and at 3, 6, 12 and 24 hours. The satisfaction level was also evaluated using a Likert-based patient questionnaire. RESULTS VAS scores decreased to 4.1±0.8 from 5.6±1.2 immediately after any nerve block, and within 3 hours, they continued to decrease to 2.0±0.6 in the FNB group and 3.4±1.0 in the ACB group (P=0.014). More patients in the FNB group were satisfied with the quality of the pain control compared to the ACB group. Additionally, patients in the ACB group required more supplemental analgesia compared to the FNB group. CONCLUSION This study demonstrated that patients with FNB had denser analgesia after arthroscopic knee surgery and had less analgesic requirement compared with ACB. Greater satisfaction scores also reflected superior analgesia in patients receiving FNB.

Patient: Male, 4 Final Diagnosis: Cortical blindness after complicated general anesthesia Symptoms: Blindness • fine motor activity derangements Medication: — Clinical Procedure: General anesthesia for unilateral inguinal hydrocelectomy Specialty: Anesthesiology Objective: Rare disease Background: We report a case of transient cortical blindness after urological surgery. Case Report: We present the case of a 4-year-old boy with visual loss following complicated general anesthesia during urological surgery. The results of ophthalmological examinations were normal. The complication was diagnosed as cortical blindness after obtaining an extinguished flash visual-evoked potential (flash VEP). The visual acuity persisted to be hand motion after 4 months. Conclusions: We report a very rare case of cortical blindness after urological surgery. Unrecognized causes of cortical blindness are common in the children. Because of the long survival and increasing surgical management in this age group, it is of great importance and perhaps it will be necessary to alert parents about it. Anesthesiologists have a unique opportunity to facilitate positive outcomes for these patients through risk identification and appropriate management.

Introduction Intra-articular injections of platelet rich plasma (PRP) for the treatment of knee osteoarthritis have been shown to reduce pain and improve joint function. The aim of this study is to examine the joint function by adding intra-articular growth hormone to platelet rich plasma. This study was performed on the individuals with knee osteoarthritis and under ultrasound guidance. Methods Fifty four patients who were scheduled for ultra-sound guided intra-articular injection were enrolled in the study. The patients were randomly allocated to groups P (platelet rich plasma) and PS (platelet rich plasma and Somatropin). Group P and PS were injected with 5 mL of platelet rich plasma, and 4 IU growth hormone (Somatropin) added to platelet rich plasma, respectively. Intra-articular injection was performed in two steps; the onset of study and one month after. Knee joint function based on Western Ontario and McMaster osteoarthritis index (WOMAC) score at the baseline, 1 and 2 month later, and complications were evaluated. Results WOMAC score in both groups has been significantly reduced after injections (P = 0.030). WOMAC score reduction in group PS in first month was significantly higher than group P, but in second month 2, the difference between two groups was not significant (P = 0.235). No complication was observed. Conclusions These results showed that adding growth hormone to platelet rich plasma for intra-articular injection improved function of the osteoarthritic knee joint in short period of time.