Background:Spinal anesthesia has been associated with intraoperative nausea and vomiting (IONV), especially during cesarean section, which is attributed to several mechanisms.Objectives:In the present study, therapeutic and preventive properties of sub hypnotic dose midazolam and propofol and their effects on the occurrence and severity of intraoperative nausea and vomiting during elective cesarean section under spinal anesthesia were evaluated.Patients and Methods:In a randomized, double-blind, and placebo-controlled clinical trial, 90 parturients, ASA class I and II, aged 20-30 years, who undergone spinal anesthesia for cesarean section were randomly allocated to one of three groups receiving midazolam (1 mg bolus and 0.1 mg/kg/hr, n=30), propofol (20 mg bolus and 0.1 mg/kg/hr, n = 30), and placebo (saline, n=30) intravenously (IV) immediately after umbilical cord clamping. Bupivacaine hydrochloride (10 mg) was used for induction of the anesthesia. Patients’ hemodynamics was monitored at 3-minute intervals. Furthermore, intraoperative and post-delivery emetic episodes, severity of emesis, scores of sedation and ephedrine consumption were recorded.Results:The incidence of nausea, retching, and vomiting was significantly higher in the control group compared to propofol and midazolam groups. Overall, PONV (postoperative nausea and vomiting) in midazolam group was as low as propofol group without any significant hemodynamic changes as seen in placebo group or even with propofol group.Conclusions:Subhypnotic doses of midazolam or propofol are effective in the prevention of nausea and vomiting during and after cesarean section with spinal anesthesia and does not significantly influence hemodynamic of the patients.

Background:Postoperative pain after major open gynecologic surgeries requires appropriate pain management.Objectives:This study aimed at comparing perioperative patient controlled epidural analgesia (PCEA) and patient controlled intravenous analgesia (PCA) after gynecologic oncology surgeries.Patients and Methods:In this clinical trial study, 90 patients with American society of anesthesiologists (ASA) class I or II scheduled for gynecologic oncologic surgeries were randomly allocated to two groups (45 patients each group) to receive: patient-controlled epidural analgesia with bupivacaine and fentanyl (PCEA group), or patient controlled intravenous analgesia (IV PCA group) with fentanyl, pethidine and ondansetron. Postoperative pain was assessed over 48 hours using the visual analog scale (VAS). The frequency of rescue analgesia was recorded. Occurrence of any concomitant events such as nausea, vomiting, ileus, purities, sedation and respiratory complications were recorded postoperatively.Results:There were no statistically significant differences in demographic data including; age, weight, ASA physical status, duration of surgery, intraoperative bleeding, and the amount of blood transfusion (P > 0.05), between the two studied groups. Severity of postoperative pain was not significantly different between the two groups (P > 0.05); however, after first patient mobilization, pain was significantly lower in the epidural group than the IV group (P < 0.001). There was no significant difference between the two groups regarding the incidence of complications such as nausea, vomiting, purities or ileus (P > 0.05). Nevertheless, the incidence and severity of sedation was significantly higher in the IV group (P < 0.001). Respiratory depression was higher in the IV group than the epidural group; this difference, however, was not significant (P = 0.11). In the epidural group, only 10 patients (22.2%) had mild and transient lower extremities parenthesis.Conclusions:Both intravenous and epidural analgesic techniques with combination of analgesics provide proper postoperative pain control after major gynecologic cancer surgeries without any significant complications. Regarding lower sedative and respiratory depressant effects of epidural analgesia, it seems that this method is a safer technique for postoperative pain relief in these patients.

Objectives: This prospective study compared the incidence of post-dural puncture headache (PDPH) in obstetric patients undergoing spinal anesthesia for caesarean section from April 2012 to April 2013 in one year. We also evaluated the relationship between needle size, number of dural punctures, timing of ambulation and PDPH after cesarean section. Materials and Methods: A total of 319 American Society of Anesthesiologists (ASA) I-II full term pregnant women, scheduled for caesarean section under spinal anesthesia from April 2012 to April 2013 were evaluated. Spinal anesthesia was performed with hyperbaric bupivacaine plus fentanyl 10 µg, from L3-4 intervertebral space. We recorded the number of attempts for spinal anesthesia, and the timing of ambulation. Each patient was monitored every day for 4 days following caesarean section. Frequency and severity of PDPH were recorded. SPSS 16 was used for data analysis. Results: Needles used were 25G Quincke spinal needle in 243 patients (76.2%) and 27G Quincke spinal needle in 76 patients (21.9%). Of 319 patients, there were 315 (95.6 %) in the late ambulation group and 14 (4.4%) in the 6 hour bed rest group. In this study only one patient had the classic symptoms of PDPH, whose spinal block were performed with 25G Quincke spinal needle by residents with more than 2 attempts of lumbar puncture (LP). Severe PDPH was not observed in 27G Quincke group. Conclusion: Although our study was performed in a teaching hospital with more residents of anesthesia attempting the procedure, the incidence of PDPH was lower in this study as compared to other studies. This study also concluded that needle size and early ambulation may have some effect on the incidence and characteristics of PDPH.

Background: Pain after laparoscopy may still be moderate to severe due to stretching of intraabdominal cavity and peritoneal inflammation. Systemic lidocaine with anti-inflammatory properties may reduce this pain. Objectives: The aim of this study was to evaluate the effect of perioperative intravenous infusion of lidocaine on postoperative pain relief after gynecologic laparoscopic procedure. Methods: A double-blind randomized clinical trial study was conducted in Iran, during years 2014 and 2015. A sample of 60 females with American anesthesiology association (ASA) physical class I or II, who were scheduled for gynecologic laparoscopy were selected through consecutive sampling and were randomly assigned to receive either intravenous lidocaine or normal saline, as placebo, prior to induction of anesthesia and until the end of surgery. Severity of postoperative pain was evaluated starting at the recovery unit until 24 hours postoperatively for a total of 8 times using the visual analogue scale (VAS) scoring system. Time to first analgesic request, total analgesic dose used in the first 24 hours, and any probable postoperative complications were recorded. Risk ratio (RR) and number needed to treat (NNT) were used to analyze the data along with generalized linear model for multivariate analysis of repeated measurements over time. Results: The VAS at recovery was lower at recovery with a mean score of 2.8 in the lidocaine group versus 3.9 in the control group (P = 0.02). Results of generalized linear modelling revealed that pain intensity decreased over time in both groups (P = 0.02), and the groups had different trend slopes in pain intensity over repeated measurements at various time points up to 24 hours after laparoscopy, while controlling for the baseline VAS at recovery and ASA PS (P = 0.016). However, when controlling for use of painkillers, the trends were not found to be different. Patients in the lidocaine group were 3.8 times more likely not to need postoperative analgesic (95% CI: 1.4 to 9.9). Mean total analgesic dose was 1.3 mg in the lidocaine group versus 38.2 mg in the control group differing significantly between the 2 groups (P < 0.01). Use of lidocaine was associated with lower postoperative nausea and agitation. Conclusions: Systemic perioperative lidocaine could improve the pain pattern and severity as well as nausea and agitation after gynecologic laparoscopy. Although no major side effects were detected in this study, the benefits of the intervention should be weighed against its safety.

Background:Pain following laparoscopy could be due to different causes requiring effective postoperative analgesia.Objectives:In the present study, we evaluated the combined effect of intraperitoneal infiltration of bupivacaine-meperidine versus intravenous infusion of paracetamol on pain relief after diagnostic gynecologic laparoscopy.Patients and Methods:In this prospective study, 90 female subjects with ASA class I or II scheduled for gynecologic diagnostic laparoscopy were studied in two groups; group B + M received intraperitoneal infiltration of 40 mL bupivacaine 0.25% with 50 mg of meperidine, group P received normal saline via abdominal trocar and ten minutes before the end of operation, group P received infusion of paracetamol 1000 mg in normal saline. Postoperative pain was evaluated using VAS score in PACU and 1, 2, 4, 8, 12 and 24 hours after the operation. The time to the first analgesic administration and total analgesic requirements were recorded.Results:Group B + M had significantly lower pain score in the first 8 postoperative hours than group P (P < 0.05). Rescue meperidine (IM) requirement was significantly less in B + M group compared to group P. Time to first request for analgesia was different between the two groups (78 versus 60 min); however, the difference was not statistically significant.Conclusions:Intraperitoneal Infiltration of bupivacaine with meperidine following surgery provided more appropriate analgesia after gynecologic diagnostic laparoscopy than administration of IV paracetamol.

Case descriptionWe describe the anesthetic management and postoperative care of a 36 years old pregnant woman with CADASIL disease who needed urgent cesarean section. According to her past medical history, she was already diagnosed as CADASIL syndrome 3 years ago. Her medical history included left hemi lateral paresis, accompanied by walking difficulties, urinary incontinence, psychiatric symptoms, apathy, diabetes mellitus, hypertension, and ovarian cyst. CADASIL diseases, was diagnosed after a hemi paretic attack when she was 32 years old. As a consequence of headache, was followed by neurologic symptoms. After admission to hospital, the clinical and neurological examination, MRI and CT-scan, and by genetic examinations, CADASIL disease was diagnosed. She got one dilatation and curettage due to a missed abortion pregnancy under sedation, 2 years ago at a primary care clinic. Now, her symptoms associated with CADASIL were intermittent headache and left hemi lateral paresis, and hypertension. She was taking methyldopa and aspirin (80 mg daily). Her diabetes was controlled by Insulin during pregnancy. She admitted to the Alzahra hospital due to hypertension one day ago. She received 5mg hydralazine and stopped aspirin. On preoperative evaluation, there were no abnormalities in laboratory tests and radiologic evaluations except slightly elevated U/A protein 1+. Her brain CT was checked two months ago revealed the confluent low densities at the subcortical and deep white matter of both cerebral hemispheres and several small old infarctions in both basal ganglia and thalami. But the neurologist who examined the patient after admission judged her still neurologically normal.Because of recent aspirin medication, we decided to conduct general anesthesia with informed consent. After premedication with ranitidine 50 mg and metoclopramide 10 mg IV, the patient was taken to the operating room. With standard monitoring (ECG, pulse oximetry, noninvasive blood pressure, and capnography) and preoxygenation, a rapid sequence induction with cricoid pressure using fentanyl, thiopental, and succinylcholine was carried out. For intubation used a cuffed 7.0 mm ETT. Neuromuscular block was achieved with atracurium, and anesthesia was maintained by controlled ventilation with an oxygen/N2O 50%/50% and isoflurane 1% mixture. With recommendations concerning the anaesthetic management of patients with CADASIL arteriopathy, we kept mean arterial blood pressure greater than 60 mm Hg and end-tidal carbon dioxide around 40 mm Hg so as to prevent any cerebral ischemic or vasospastic phenomenon. Patient's blood sugar within the perioperative was in the normal range. Moreover, the cerebral venous return was preserved by the patient received 8 ml/kg of ringer's solution in the left lateral position. The condition of neonate was assessed by apgar score at 1 st and 5 th after delivery who was 8 and 9 respectively. Mother received oxytocin 5 IU by continues infusion after delivery. Surgery and recovery were uneventful. The neurological examination ...

No abstract

No abstract