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Peripheral nerve blocks (PNB) have become standard of care for enhanced recovery pathways after surgery. For brachial plexus delivery of anesthesia, both supraclavicular (SC) and infraclavicular (IC) approaches have been shown to require less supplemental anesthesia, are performed more rapidly, have quicker onset time, and have lower rates of complications than other approaches (axillary, interscalene, etc.). Ultrasound-guidance is commonly utilized to improve outcomes, limit the need for deep sedation or general anesthesia, and reduce procedural complications. Given the SC and IC approaches are the most common approaches for brachial plexus blocks, the differences between the two have been critically evaluated in the present manuscript. Various studies have demonstrated slight favorability towards the IC approach from the standpoint of complications and safety. Two prospective RCTs found a higher incidence of complications in the SC approach – particularly Horner syndrome. The IC method appears to support a greater block distribution as well. Overall, both SC and IC brachial plexus nerve block approaches are the most effective and safe approaches, particularly under ultrasound-guidance. Given the success of the supraclavicular and infraclavicular blocks, these techniques are an important skill set for the anesthesiologist for intraoperative anesthesia and postoperative analgesia.

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.

Controlled hypotension, with a mean arterial pressure (MAP) of 60 mmHg - 70 mmHg, provides a bloodless and visible surgical field during rhinoplasty. It has been shown that dexmedetomidine, an α2-adrenoreceptor agonist, is a suitable choice in this regard. One of the disadvantages of this drug is the possibility of severe bradycardia during infusion. Therefore, we compared lower intravenous (IV) loading doses to determine whether the hypotensive effect of the drug was preserved and the bradycardia incidence decreased. In this randomized, double-blinded clinical trial, 81 patients aged 18 to 50 years with the American Society of Anesthesiologists physical status (ASA-PS) class I and II, scheduled for rhinoplasty randomly received 1.0, 0.9, and 0.8 µg/kg (named as groups 1.0, 0.9, and 0.8, respectively) of IV dexmedetomidine before the induction of anesthesia followed by infusion (0.3 - 0.7 µg/kg/h) during operation. The patients’ heart rate (HR), MAP, the requirements for nitroglycerin (NTG) and extra fentanyl, as well as the incidence of bradycardia, were recorded. Bleeding and visibility of the surgical field were scored by the surgeon using a 6-point visual scale. MAPs, HRs, and consumption of NTG and extra fentanyl were similar in the studied groups. The surgical field was more visible and bloodless in group 1.0 compared to group 0.8 (P < 0.001); the differences were not significant between groups 1.0 and 0.9 (P = 0.605). The incidence (P = 0.027) and the severity of bradycardia (P = 0.017) were higher in the groups with higher loading doses. We concluded that dexmedetomidine is an acceptable agent to provide controlled hypotension. A loading dose of 0.9 µg/kg, but not 0.8 µg/kg, provides similar surgical field conditions as the dose of 1 µg/kg. Furthermore, despite the decrease in the incidence of bradycardia, the hypotensive effect of the drug is preserved.

Background: Postoperative cognitive dysfunction (POCD) and delirium are common in the elderly patients, given the controversial results of previous studies about the impact of anesthesia type on the occurrence of these complications. Objectives: This study was planned to compare the effects of general and spinal anesthesia on the prevalence of POCD and delirium. Methods: A single-blind non-randomized clinical trial. Setting was in two academic hospitals. Ninety-four patients over 50 years old scheduled for hip fracture fixation. Patients were divided into two groups to receive either general (GA) or spinal (SA) anesthesia. Both Mini-Mental State examination (MMSE) and Wechsler tests were used before the operation and 3 times postoperatively to assess the cognitive function and detect early POCD. The DSM-IV criteria were also used for the diagnosis of delirium. The incidence of delirium and POCD and their precipitating factors were compared between the two groups. Results: Ninety-four patients with a mean age of 67.12 years were studied. The overall prevalence of POCD and delirium was 17.02%; however, it was significantly higher in the GA group rather than the SA group, 29.7%, and 4.25%, respectively (P < 0.001). There was a significant relationship between age (P = 0.048), ASA class (P = 0.034), and educational level with the incidence of POCD, meaning that the probability of developing cognitive impairment decreases with patients’ higher level of education and lower ASA-physical status. Also, the rate of POCD in men was significantly higher than in women (P = 0.026). Conclusions: The finding of this study showed that, if there is no specific contraindication, neuraxial anesthesia may be preferred over general anesthesia in elderly patients.

Background Intra-operative ventilation is often challenging in patients with morbid obesity undergoing bariatric surgery. Objectives To test the noninferiority of pressure-controlled ventilation (PCV) to volume-controlled ventilation (VCV) in respiratory mechanics. Setting Bariatric Surgery Center, Iran. Methods In a randomized open-labeled clinical trial, 66 individuals with morbid obesity undergoing laparoscopic bariatric surgeries underwent intraoperative ventilation with either PCV or VCV. The measurements taken were peak and mean airway pressures (H2O), partial pressure of arterial oxygen (PaO2), partial pressure of arterial carbon dioxide (PaCO2) and end-tidal carbon dioxide (CO2). We additionally collected pulse-oximetric oxygen saturation, inspiratory concentration of oxygen (FiO2), and hemodynamic variables. Data were analyzed with repeated measures over the time of intubation, after peritoneal insufflation, and every 15 minutes, thereafter up to one hour. Results PCV mode was successful to sustain adequate ventilation in 97% of the patients, which was similar to the 94% success rate of the VCV mode. Peak airway pressure increased 6 cmH2O and end-tidal CO2 rose by 5 mm Hg after abdominal insufflation in both groups (P = .850 and .376). Alveolar-arterial oxygen gradient similarly increased within 30 minutes after tracheal intubation both in PCV and VCV groups, with small trend of being higher in the VCV group. The ratio of dead space to tidal volumes (VD/VT) did not have a meaningful change (P = .724). Conclusion PCV was noninferior to VCV during laparoscopic bariatric surgery. Either mode of ventilation could be alternatively used during the anesthesia care of these patients.

Postoperative pain has many adverse effects and, if not properly controlled, it may lead to a wide range of complications. Opioids, as frequently used drugs for pain control, have some serious respiratory and gastrointestinal complications, especially in obese patients.In this study, we planned to evaluate the effect of intraperitoneal bupivacaine lavage on postoperative pain in laparoscopic bariatric surgeries.The study was conducted in Firoozgar Hospital (affiliated to Iran University of Medical Sciences), Tehran, Iran.In this clinical trial, 106 patients scheduled for laparoscopic bariatric surgery, randomly assigned to receive either intraperitoneal lavage with 50 mL of .2% bupivacaine or the same volume of normal saline during the operation. One-gram intravenous paracetamol was infused for all patients at the end of surgery, and all patients received intravenous paracetamol infusion for 1 day after surgery. Pain level, assessed by visual analog scale, was recorded at 1, 4, 8, and 24 hours after surgery. Total additive analgesics administered during the first day after surgery was also recorded.The pain score during the first 24 hours after surgery decreased significantly in both groups, but comparing the groups showed that pain level at 1, 4, 8, and 24 hours after surgery in the bupivacaine group was significantly lower than the normal saline group (P.05). Also, opioid consumption during 24 hours was significantly lower in the bupivacaine group (P.001).Intraperitoneal lavage with bupivacaine is an effective approach to control postoperative pain in obese patients undergoing laparoscopic bariatric surgery.

Background Pain is a common complain after surgeries, which leads to severe complications. Objectives Elucidating the effect of intraoperative hypertension on post-operative pain after hysterectomy was the main aim of the current study. Methods In this randomized controlled clinical trial that was conducted at Firoozgar Hospital, Tehran, Iran, 78 candidates for hysterectomy with past medical history of hypertension were randomly allocated to two groups. In group A, blood pressure was maintained in the range of stage 1 by dose adjustment of the anesthetic drugs. However, in group B, blood pressure was maintained in the normal range (SBP ≤ 120, DBP ≤ 80), by administration of anesthetic drugs and TNG drip. Preoperative and intra operative data (hematocrit, blood pressure, heart rate, operating time, and blood loss) and recovery data, including blood pressure, heart rate, pain score at two, four, six, 12, and 24 hours using VAS (after surgery), and pain relief medicine requirements after 24 hours were recorded for all patients and analyzed by SPSS 22.0. Results Systolic and diastolic blood pressure before surgery did not show any significant differences (P ≥ 0.05). A significant decrease was found in systolic (P ≤ 0.001) and diastolic (P ≤ 0.014) blood pressure during surgery between groups. Comparing VAS and the need for pain relief drugs revealed no significant differences. However, a reduction of pain score was observed in the hypertensive group from the 2nd to 24th hour after surgery. Conclusions No significant differences were shown between pain score and opioid requirement after surgery in hypertensive patients compared to normotensive during abdominal hysterectomy.

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: The current study aimed at comparing the efficacy of dexmedetomidine and magnesium sulfate to control blood pressure (BP) during rhinoplasty and the resultant effects on the quality of surgical field in terms of bleeding and visibility. Methods: The current randomized, prospective, double-blind study was conducted on 60 patients aged 18 to 50 years classified as ASA (American Society of Anesthesiologists) physical status I who were candidates for rhinoplasty. Patients were randomly divided into 2 groups: (1) group Dex, received 1 µg/kg dexmedetomidine in 10 minutes before induction of anesthesia, followed by 0.4 - 0.6 µg/kg/hour during the maintenance of anesthesia, and (2) group Mg, received 40 mg/kg in 10 minutes before anesthesia induction followed by 10 - 15 mg/kg/hour during anesthesia maintenance. In both groups, the goal was to achieve a mean arterial pressure (MAP) of 60 - 70 mmHg. Hemodynamic variables, anesthetic, opioid, muscle relaxant requirements, and surgical field condition were recorded. Sedation score, time to reach modified Aldrete score � 9, and adverse effects including nausea and vomiting (N&V) and shivering were recorded. Results: Controlled hypotension was achieved in both groups. There was no significant difference in MAP between the groups, but heart rate (HR) was significantly lower in the Dex group (P < 0.001), compared with that of the Mg group. Bleeding score was lower (P < 0.001) and surgeon�s satisfaction score was higher (P < 0.001) in the Dex group. More patients required fentanyl (P < 0.001) or nitroglycerin (P < 0.001) and the mean fentanyl (P = 0.005) or nitroglycerin (P < 0.001) required doses were higher in the Mg group. Patients in the Dex group required more frequent administration of cisatracurium (P = 0.004). Five patients in the Dex group versus no patients in the Mg group received atropine (P = 0.023). Ramsay sedation score and time to reach modified Aldrete score � 9 were significantly higher in the Dex group (P < 0.001 and P < 0.001, respectively). The incidence rate of N&V and shivering were similar in both groups. Conclusion: Dexmedetomidine was more effective than magnesium to achieve controlled hypotension, and provide a favorable surgical field condition. However, dexmedetomidine also heightened the risk of induced bradycardia and prolonged sedation. These are 2 important points to consider when applying this drug as a hypotensive agent during operation. © 2017, Anesthesiology and Pain Medicine.