Background:The caudal approach to the epidural space has been used for decades to treat low back pain caused by lumbosacral root compression. The use of fluoroscopy during epidural steroid injection is the preferred method for placing the needle more accurately in the sacral hiatus, but it carries the risk of radiation hazard.Objectives:The aim of the study was to assess the anatomical structure of the sacral hiatus and the feasibility of caudal epidural injections under ultrasound guidance.Patients and Methods:Two hundred and forty patients (male = 100, female = 140) with low back pain and sciatica who were candidates for caudal epidural injection were enrolled into this study. Ultrasound images of the sacral hiatus and bilateral cornua were obtained by a real-time linear array ultrasound transducer. The distance between bilateral cornua and the anterior and posterior wall of the sacrum were measured at the base (sacral hiatus). Under the guide of ultrasonography, we defined the injection successful if turbulence of medication fluid was observed in the sacral canal, but correct placement of the needle and injectant was confirmed on fluoroscopic view as the gold standard technique.Results:The epidurogram showed that the injection was successful in 230 of the 240 patients (95.8%). In eight patients, the injection was not in the correct place in the sacral canal. The sacral hiatus could not be identified by ultrasound images in only two patients who had a closed sacral hiatus identified by fluoroscopy. The mean distance of the sacral hiatus was 4.7 ± 1.7 mm and the mean distance between bilateral cornua was 18.0 ± 2.8 mm. The mean duration of the procedure was 10.8 ± 6.8 minutes. No major complication was observed in the next month.Conclusions:In conclusion, ultrasound could be used as a safe, fast and reliable modality to observe the anatomic variation of the sacral hiatus and to perform caudal epidural injections.

BackgroundDespite controversies about the safest anesthetic technique for cesarean delivery in severely preeclamptic women, there is evidence that supports the use of spinal anesthesia in this group of patients.ObjectivesThis prospective randomized clinical trial was designed to determine the hemodynamic effects of low-dose spinal bupivacaine and the incidence of spinal anesthesia-associated hypotension in severely preeclamptic and healthy parturients undergoing cesarean sections.Patients and MethodsSpinal anesthesia was performed with 10 mg (= 2 mL) hyperbaric 0.5% bupivacaine plus 2.5 µg sufentanil in two groups of patients after they received 500 mL of IV lactated Ringer’s solution. Heart rate and blood pressure were recorded before spinal anesthesia and at two minutes intervals for 15 minutes after the block, and then every five minutes until the end of the surgery. Hypotension was defined as more than 25% of decline in the mean arterial blood pressure compared to the baseline in both groups (or systolic blood pressure < 100 mmHg in healthy parturients) and was treated with 5 mg IV ephedrine. The total amounts of intravenous administered fluid and the total doses of ephedrine were recorded for each patient as well.ResultsThe incidence rate of hypotension among the preeclamptic patients was lower than that of the healthy parturients, despite the former group receiving smaller volumes of intravenous fluids (P < 0.05). The total doses of IV ephedrine for treating hypotension were significantly lower among the preeclamptic patients (3.2 mg in preeclamptic patients versus 7.6 mg in normotensive patients) (P = 0.02). The one-minute Apgar score was significantly lower for the preeclamptic parturients (8.4 ± 0.7 versus 7.2 ± 1.5) (P = 0.001), but there was no significant difference in the five-minute Apgar scores between the two groups.ConclusionsOur results confirm that low-dose bupivacaine spinal anesthesia is associated with a lower risk of hypotension than previously believed, and it can therefore be safely used in severe preeclamptic women undergoing cesarean delivery.

Background: There is a growing trend in ultrasound use in interventional pain management. Recently, the ease of use and clinical benefits of lumbar medial branch nerve block under ultrasound guidance have been identified.

Background:Tonsillectomy is one of the most common surgeries in children and posttonsillectomy pain and agitation management is a great challenge for anesthesiologists.Objectives:The aim of this study was to compare the efficacy of a single dose of ketamine combined with paracetamol with paracetamol alone in the management of postoperative pain in tonsillectomy.Materials and Methods:In this study, the subjects were randomly allocated into the two groups: the ketamine and control. Intravenous paracetamol infusion (15 mg/kg) was started 15 minutes before the end of surgery in both groups, continued with the IV injection of ketamine (0.25 mg/kg) in the ketamine group and an equal volume of saline in the control group. Using the children’s hospital of eastern Ontario (CHEOPS) pain scale, pain and agitation score and also the incidence of nausea and vomiting after the surgery were recorded in 0.5, 6 and 12 hours after the operation. Data were analyzed using SPSS software version 16 and P value less than 0.05 was considered as statistically significant in all cases.Results:There was no significant difference between the two groups considering demographic data (age, sex distribution, weight and height). The CHEOPS pain scales were significantly lower in the ketamine group compared to the control group at 0.5 and 6 hours after the surgery (P = 0.003 and P = 0.023, respectively). There was no significant difference in the CHEOPS scale at 12 hours after the surgery, dose of adjuvant analgesic and the incidence of nausea and vomiting after the surgery between the two groups.Conclusions:According to the results of the current study, postoperative analgesia in children was improved in the ketamine group. Therefore, for better management of posttonsillectomy pain, low-dose ketamine administration with paracetamol is recommended.

Background: Critically ill patients admitted to intensive care units (ICUs) frequently experience pain, but the severity of pain in this group of patients is underestimated by the treatment team due to barriers to verbal communication. The aim of the present study was comparing the severity of pain measured by two scales: behavioral pain scale (BPS) and critical-care pain observation tool (CPOT) in ICU-admitted patients during routine daily procedures. Materials and Methods: Ninety patients were enrolled in the study. The severity of pain was measured during resting, invasive (suctioning) and noninvasive (mouthwash and body position change) procedures, and respiratory physiotherapy with two scales: BPS and CPOT. Wilcoxon and Friedman statistical tests were used to compare the score of pain in different situations, and Spearman correlation coefficient was also used to measure the correlation of pain score measured by two scales. Results: Patients experienced no pain during resting, mild pain during changing position, and respiratory physiotherapy, mild-to-moderate pain during mouthwash and moderate pain during secretion suctioning. Wilcoxon test used for pairwise comparisons between pain score in different situations showed a significant difference in both scales ( p < 0.05). There were positive and strong correlations ( r > 0.80, p < 0.05) between the pain score measured by BPS and CPOT from ICU-admitted patients in all procedures. Conclusions: Critically ill patients in ICU experience a different range of pain in routine daily care. BPS and CPOT scales could be used successfully for monitoring of pain in this group of patients.

Background. Prolonged preoperative fasting is one of the concerns of pediatricians and anesthesiologists in pediatric surgery. The aim of this study was to assess the impact of preoperative fasting duration on blood glucose and hemodynamics in children. Methods. This cross-sectional study was conducted on 50 children who were between the ages of 3 and 12 years in Besat Hospital, Hamedan, Iran. The time of the last solid and liquid meal taken by child were recorded based on interview with the parents. The first blood glucose test was obtained in the operation room, and the second test was performed 20 minutes after induction of anesthesia by glucometer. Systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) were recorded before anesthesia induction and in five-minute intervals in the first 20 minutes of surgery. Results. The mean age of the children was 6.63 (SD 1.85) years. Mean blood glucose 20 minutes after surgery was 101.17 (SD 92) mg/dl, which was significantly higher than the baseline values (87.66 (SD 11.84) mg/dl) (P<0.001). The comparison of mean blood glucose level between groups of fasting with different duration for solids (<12 hours and >12 hours) and for liquids (<6 hours and >6 hours) revealed no significant difference in either groups (P>0.05). No significant correlation was observed between blood glucose level at the induction of anesthesia with weight and age (P>0.05). There was a significantly negative correlation between duration of fasting for liquids and SBP (P>0.05). Conclusion. Prolonged preoperative fasting cannot affect blood glucose in children; however, maybe it has impact on systolic blood pressure.

Background: Phenylephrine is used to prevent and treat hypotension during spinal anesthesia for cesarean delivery. Objectives: The present study aims to investigate the effects of different regimens of phenylephrine on blood pressure of candidates for the cesarean section. Methods: In this double-blind, randomized clinical trial, a total of 120 candidates of elective cesarean delivery under spinal anesthesia was randomly categorized into three groups. Groups 1, 2, and 3 received bolus and prophylactic saline (control group), prophylactic bolus phenylephrine (100 µg), and prophylactic phenylephrine infusion (50 µg/min), respectively. The incidence of hypotension, maternal hemodynamics, hypertension, rescue phenylephrine dose, nausea, and vomit were compared between the groups. Results: In all the three groups, the incidence of nausea and vomit, bradycardia, hypertension, and neonatal Apgar score were not statistically different (P > 0.05). However, the adjuvant phenylephrine dose requirement was remarkably different. Moreover, the mean systolic blood pressure differed significantly in the second and 7th minutes after the spinal block (P < 0.05). 35% in the first group, 15% in the second group, and 2.5% in the third group had hypotension (P = 0.001). Apart from the first measurement after spinal anesthesia, the mean heart rate showed no significant difference between the groups. Conclusions: The use of prophylactic phenylephrine infusion is recommended to control the optimal blood pressure in parturients undergoing cesarean section after spinal anesthesia.

Background: Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks. Objectives: This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time. Methods: In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI. Results: The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.52 ± 1.83 vs 1.5 ± 2.84 (P = 0.03) on the first day, 0.70 ± 2.19 vs 1.58 ± 2.86 (P = 0.05) on the second day, and 0.82 ± 2.32 vs 1.18 ± 2.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups. Conclusions: In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.