Tehran University Medical Journal

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Burning Transient Neurologic Syndrome (TNS) which was first described by Schneider et al in 1993, is defined as a transient pain and dysesthesia in waist, buttocks and the lower limbs after spinal anesthesia.1,2 The incidence of TNS after spinal anesthesia with lidocaine is reported to be as high as 10-40%.3,4 This prospective study was designed to determine the incidence of TNS with two different types of drugs, lidocaine and bupivacaine, in lithotomy or supine positions as the primary outcomes and to determine the association between two different types of needles and surgical positions with the occurrence of TNS as the secondary outcome. The present study was conducted on 250 patients (ASA I-II), aged 18-60 years old, who were candidates for surgery in supine or lithotomy positions. According to the needle type (Sprotte or Quincke) and the local anesthetic (lidocaine or bupivacaine) all patients were randomly divided into four groups. After establishing standard monitoring, spinal anesthesia was performed in all sitting patients by attending anesthesiologists at L2-L3 or L3-L4 levels. The patients were placed in supine or lithotomy position, in regards to the surgical procedure. During the first three postoperative days, patients were observed for post spinal anesthesia complications, especially TNS. Any sensation of pain, dysesthesia, paresthesia or hyperalgesia in the low back area, buttocks, the anterior or posterior thigh, knees, either foot or both feet were recorded. Moreover, duration of pain, its radiation and its relation to sleep and the patients' position were all carefully considered. Ultimately, the patients' response to opioid (pethidine) for analgesia was determined. The incidence of TNS was higher when spinal anesthesia was induced with lidocaine (68% vs. 22%, P=0.003). TNS developed in 85% of the patients in lidocaine group and 58% in bupivacaine group after surgery in lithotomy position (P=0.002). In 77 patients pain was in lumbosacral area that radiated to lower limbs and was aggravated in sitting position but in 22 patients pain was in thighs with no radiation. The mean visual analogue scale (VAS) for the determination of pain severity was six in all patients. Pain was alleviated by the administration of pethidine. With regard to the needle type, there were no significant differences between the two types of needles (P=0.7). According to the results of this prospective study, it seems that induction of spinal anesthesia by lidocaine combined with surgical lithotomy position increases the risk of TNS. Our study is in concordance with Keld's study.5 Higher neurotoxicity of lidocaine in comparison with bopivacaine may justify the higher incidence of TNS in the lidocaine group. Moreover, natural lumbar lordosis is maintained better in supine position while it is lost in lithothomy position which may lay traction forces on cauda equina or other nerve roots in the lumbar area leading to neuropraxia.

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Background: Renal transplantation is the preferred therapeutic method for patients with end-stage renal disease. Patients with renal failure have significant associated medical conditions, such as cardiovascular disease. The suitable anesthesia for renal transplantation requires minimal toxicity for the transplanted organ, as well as sufficient pain relief and maintenance of optimal blood pressure and intravascular volume to keep renal functions. The aim of this study was to improve our experience of spinal anesthesia in patients undergoing renal transplantation.
Methods: Sixty consecutive patients scheduled for elective renal transplantation over a period of two years who consented for spinal anesthesia were enrolled in the study. Intraoperative hemodynamic, intravenous fluids and infused blood products, duration of surgery, urine output and arterial blood gas and intensity of pain score in the recovery room were monitored. We also noted intraoperative and postoperative complications.
Results: Spinal anesthesia was satisfactory in all, but in five patients they required supplementation with general anesthesia for excessively prolonged surgery. There were no significant intraoperative hemodynamic changes. The total intravenous fluid used during surgery was 65.15±7.2 mL/kg, the mean surgical time was 170±22 min. The mean of mean arterial pressure (MAP) during the operation was 98±12 mmhg. There was no significant acidosis at the end of the operation (PH=38±0.03). Also the mean intensity of pain was 4±2 in recovery and a few of patients suffered from bladder catheter bladder discomfort in the recovery room (8 patients).
Conclusion: Spinal anesthesia is a successful regional anesthetic technique in well selected patients for renal transplantation. A successful outcome in this technique is dependent on close intra-operative monitoring, optimization of intravascular fluid volume and keep the hemodynamic status in optimal range.

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Background: The Trigemino-cardiac reflex (TCR) has been studied as a phenomenon including bradycardia, arterial hypotension, apnea and gastric hypermotility during manipulation of the peripheral or central parts of the trigeminal nerve.
Case presentation: We report a case of a 26-year-old man undergoing surgery for a skull base extra axial tumor in right petrous bone suspected to metastasis of a previous renal cell carcinoma which had been treated four years ago. The patient presented with continuous and unilateral headache and difficulty in swallowing, sensory neural hearing loss, nasal speech and tongue deviation to left side. He underwent general anesthesia with standard monitoring and total intravenous anesthetic technique. The first episode of sudden onset bradycardia and hypotension related to surgical manipulation was detected intraoperatively in which the heart rate spontaneously returned to normal level once the surgical manipulation stopped. However, it repeated several times by beginning of tumor resection and manipulation in the region of trigeminal nerve. The intensity of bradycardia in subsequent episodes of TCR was relatively crescendo and had no fatigability. Finally, it was treated by administration of a single dose of atropine (0.5mg/IV) and did not happen again.
Conclusion: The risk of TCR should be considered in any neurosurgical intervention involving trigeminal nerve and its branches, especially at the skull base surgeries. The vigilance of the medical team and continuous intraoperative hemodynamic monitoring alerts the surgeons to interrupt surgical maneuvers upon the TCR occurrence, immediately.

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Background: Today Anesthesiologists occasionally face with bradycardia during gastric surgery and recognized this phenomenon as a vagal reflex. The objective of this study is finding of anesthesia risk factors for bradycardia and prevention of its hazardous complications during gastric surgeries. Methods: In this retrospective study, fifty patients undergoing laparatomy and gastric surgery in Sina hospital between September 2009 to September 2013. They had been anesthetized with propofol or thiopental and their maintenance was kept by isoflurane or propofol were enrolled. The age, gender, underlying diseases, drug history, chemotherapy, kind of surgery, heart rate variability, onset time of bradycardia and its complication during a period of four years was noted. Results: Of Fifty patients, 31 males and 19 females was enrolled in this study. The mean age of patients was 48±8.3 yr all patients had laparatomy under general anesthesia. The kind of surgery were mainly gasterectomy and gastrojejunostomy. The mean onset of episode bradycardia was 24.5±3.5 min after initiation of surgery incision, and most of the bradycardia was mild to moderate (47 patients) that with injection of atropine it resolved. There was no relationships between anesthetic drugs and anesthetic maintenance, age, gender, and incidence of bradycardia event during the surgery. The risk factors of bradycardia were, diabetes mellitus in seven patients, use of beta blockers in 17 patients in perioperative period and gastric cancer and chemotherapy (neoadjuant therapy) in three patients that lead to asystole, they were not response to standard treatment during surgery and lead to death. Conclusion: The history of gastric cancer and previous chemotherapy might be the only common factors that cause to bradycardia and irresponsible asystole during gastric surgery in these patients. It seems that only close monitoring and vigilant anesthesiologist require for treatment and prevention from adverse effect of such a sever bradycardia event.

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Background: Pain control after orthognathic surgeries due to severity of pain and limitations of opioids use in these patients are particular importance. The aim of this study was to evaluate the effect of oral gabapentin and intramuscular ketorolac in combination with intravenous acetaminophen for pain control after this surgery.

Methods: This study was a randomized clinical trial (RCT) on 75 patients (18-60 years old American Society of Anesthesiologists (ASA) physical status classification system, I, II) that undergo orthognathic surgery in Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran from June 2013 to August 2014. The patients were randomly divided in 3 groups. All of groups received 1 gr (intravenous acetaminophen) 30 minutes before the end of surgery. The control group (n= 25) received placebo. The second group (n= 25) received 30 mg ketorolac intramuscular after induction of anesthesia and the third group (n= 25) received 600 mg Gabapentin orally 30 minute before the induction of anesthesia. The pain severity score assessed by visual analogue scale (VAS), the level of sedation assessed by Ramsey scale, opioid requirement, nausea and vomiting was recorded in the post-anesthesia care unit (PACU) at 1, 3, 6, 12 and 24 hours after surgery. For rescue pain management intravenous morphine was administered.

Results: Seventy-five patients were enrolled in this study. Use of Ketorolac and gabapentin declines the pain intensity, level of agitation and morphine requirement in the recovery room and early hours in the ward (P= 0.011). The 24-hour opioid consumption, nausea and vomiting was significantly higher in control group compared with the both intervention groups (15±1.4 vs. 5±0.5 mg) (P< 0.05) retrospectively. Mean arterial pressure and heart rate changes was significantly lower in ketorolac and gabapentin groups compare to control group in recovery room (P< 0.05).

Conclusion: The result of this study suggest that ketorolac as well as gabapentin can decline the pain intensity and opioid requirement with less nausea and vomiting and good hemodynamic control after orthognathic surgery.

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Conclusion: Although Nicolau syndrome is a very rare complication with no definitive treatment but can be prevented and not be aggravated by doing proper method of intramuscular injection and no application of cold compress (aspiration the needle for 5–10 seconds before injecting to make sure not to hit a blood vessel, the proper method of z-track, holding injection immediately if the patient complains excruciating pain on injection site, appropriate length of the needle to reach muscle, and different sites for multiple injections). However, due to lack of supporting evidence, needle aspiration is not recommended because no major vessel runs through the normal vaccination zone and that faster method is less painful. So, the vaccination must be done in right place with an appropriate length of the needle.

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Results: In the glide scope group, 76% of students were able to see the epiglottis and larynx in 20 seconds, but in the Macintosh group, 43% of students were able to see the larynx in 20 seconds. In terms of endotracheal intubation time, 72% of the students in the glide scope group were able to successfully perform endotracheal intubation within 40 seconds in their first attempt, but in the Macintosh group, 44% completed endotracheal intubation within 40 seconds (P=0.00). In the evaluation of the quality of skill, the average score of the students in the Macintosh group was 15.30±0.56, while the average score in the glide scope group was 17.20±0.83 (P=0.00). The scores and satisfaction of the students in the glide scope group were higher than the Macintosh. Conclusion: The use of video laryngoscope in teaching of intubation in trainees will increase the speed, and accuracy of their training and satisfaction compared with the Macintosh laryngoscope.