Fentanyl-induced cough (FIC) refers to a cough that can occur as a side effect of fentanyl, an opioid analgesic primarily used for pain management. Both lidocaine (LIDO) and dexmedetomidine (DEX) are effective in preventing FIC, but the comparative efficacy of each has not yet been thoroughly investigated. In this study, we aimed to compare the effect of LIDO versus DEX in preventing FIC in adult patients undergoing elective surgery. A total of 171 adult patients with American Society of Anesthesiologists (ASA) class I or II undergoing elective surgery were enrolled in this blinded, randomized, placebo-controlled trial. Patients received either 0.5 μg × kg-1 of DEX in 10 mL of isotonic saline, 1.5 mg × kg-1 LIDO, or a matching placebo (equal volume of 0.9% saline) prior to fentanyl injection. The incidence and severity of cough were recorded within the two minutes following fentanyl administration. Hemodynamic parameters were measured at different time intervals. Statistical analysis was performed using SPSS version 18. The incidence of cough among groups was compared using the Pearson chi-square test, while continuous hemodynamic variables were analyzed using one-way ANOVA followed by Tukey's post-hoc test. A two-tailed P-value < 0.05 was considered statistically significant. The study was registered at the Iranian Registry of Clinical Trials (IRCT20211023052848N1). The incidence of cough was 7.0%, 10.5%, and 33.3% in the DEX, LIDO, and saline groups, respectively (P < 0.001). There was no significant difference between the DEX and LIDO groups (P = 0.453), but both were significantly more effective than the control group (P < 0.001 for DEX vs. saline; P = 0.002 for LIDO vs. saline; P < 0.001 for DEX reduced heart rate, systolic and diastolic blood pressure). The results of this study demonstrated that 0.5 μg × kg-1 of DEX and 1.5 mg × kg-1 of LIDO are equally effective in preventing FIC. However, hemodynamic parameters are more markedly suppressed in the DEX group compared to the lidocaine group.

Post-cesarean section (CS) pain satisfaction remains an issue. The purpose of this research was to evaluate the effectiveness of the transversus abdominis plane (TAP) block in comparison to intravenous analgesia controlled by patients for managing pain after CS in Iraq. The study aimed to evaluate pain intensity as the primary outcome, alongside secondary outcomes including vital signs, nausea, vomiting, medication use, and inflammatory markers. A quasi-experimental study was conducted at Wasit Investment Hospital in Kut, Iraq, involving 78 pregnant women undergoing elective CS. Sampling was conducted among eligible women who signed an informed consent form. Participants were classified into two groups based on the type of analgesia received after CS. The first group included women who received a TAP block using bupivacaine (n = 39). The second group consisted of those who used a patient-controlled analgesia (PCA) pump containing nalbuphine (n = 39). Pain intensity was measured using the Short Form McGill Pain Questionnaire (SF-MPQ; Arabic version) at 2, 4, 6, 12, and 24 hours following the CS. Laboratory tests, including a complete blood cell count (CBC) and high-sensitivity C-reactive protein (hs-CRP), were performed 24 hours after surgery. There were no notable differences in the demographic, clinical, or laboratory characteristics between groups (P > 0.05). Pain levels assessed using the SF-MPQ at 2, 4, and 6 hours post-surgery were notably lower in the TAP block group than in the PCA group (P = 0.009, P = 0.005, and P = 0.001, respectively). A positive and significant relationship between hs-CRP levels and pain intensity was identified across all measurement times in the TAP block group. The findings of this study showed that the use of a TAP block technique provided more effective pain relief than PCA during the first 6 hours after a CS.

Midazolam is widely used for its anxiolytic and amnestic effects, while dexmedetomidine provides sedation and analgesia, and ketamine induces sedation, analgesia, and amnesia. Oral administration is commonly accepted in children undergoing inguinal hernia surgeries. This study aimed to examine oral dexmedetomidine, ketamine, and midazolam as premedication in children having inguinal hernia operations. This randomized, double-blind study included 60 children (ages 3 - 7, ASA I-II) who underwent inguinal hernia operations. Subjects were randomly assigned to 3 groups: Group K received oral ketamine at 6 mg/kg, group D received oral dexmedetomidine at 4 µg/kg, and group M received oral midazolam at 0.5 mg/kg. No substantial differences were seen in the five-point sedation score (P = 0.2811) or the Parental Separation Anxiety Scale (PSAS; P = 0.1122). Group D had a markedly reduced recovery time in comparison to groups M and K (P < 0.001). Furthermore, group D exhibited markedly reduced face, legs, activity, cry, and consolability (FLACC) scores at 15 and 20 minutes compared with groups M and K (P = 0.001, 0.016, respectively). Oral dexmedetomidine, ketamine, and midazolam provided comparable sedation quality and parental separation ease in children undergoing inguinal hernia surgeries. However, dexmedetomidine showed significant advantages by reducing recovery time and improving postoperative pain scores, despite a higher incidence of bradycardia in some patients. Thus, oral dexmedetomidine appears to be an efficient and safe alternative for pediatric premedication, provided careful heart rate monitoring.

BackgroundNumerous medical interventions have been utilized to prevent postoperative shivering. Due to the potential complications associated with the use of pethidine, such as respiratory failure, the exploration of alternative drugs for the prevention and treatment of postoperative shivering has been a key consideration.ObjectivesThe aim of this study was to assess the preventive effects of ketamine and dexmedetomidine on shivering in patients undergoing inguinal herniorrhaphy under spinal anesthesia.MethodsThis triple-blind randomized clinical trial involved patients who were candidates for inguinal herniorrhaphy with spinal anesthesia. Patient, investigator/administering, and outcome assessor were blinded. The necessary sample size was 150, estimated based on statistical formula at a 95% confidence interval and 80% power. Patients were randomly assigned using a computer-generated random sequence allocation and a randomized block sampling design with block sizes of six to ensure balanced allocation across the three groups: Ketamine, dexmedetomidine, and control. Randomization was performed using random sequence allocation software and randomized block sampling with 6 blocks for all 3 treatment groups. The severity of shivering was assessed using the Bedside Shivering Assessment Scale (BSAS) at multiple time points: Immediately, 5, 15, and 30 minutes after spinal anesthesia, and upon entering the recovery room, 15 minutes later, and at discharge from recovery. Data were analyzed using IBM SPSS Statistics version 21 software. Quantitative data were expressed as mean ± standard deviation, while qualitative data were presented as percentages. The mean of the variables was compared using Student's t-test, and the chi-square test was employed to compare qualitative data.ResultsThe severity of shivering was notably lower in the dexmedetomidine group at 5, 15, and 30 minutes after spinal anesthesia induction, during recovery, and 15 minutes after recovery. The intensity of shivering upon exiting recovery was similar in the ketamine and dexmedetomidine groups and significantly lower than in the control group. Systolic blood pressure was significantly lower in the dexmedetomidine group upon entry into recovery and 15 minutes after recovery. Throughout all time periods, patients in the dexmedetomidine group exhibited significantly lower heart rates.ConclusionsBoth ketamine and dexmedetomidine proved effective in reducing post-herniorrhaphy shivering compared to the control group, with the effect being notably greater in the dexmedetomidine group.

BackgroundInterscalene brachial plexus block (ISB) remains the gold standard for analgesia in arthroscopic shoulder surgery (ASS). However, ISB is associated with a higher incidence of hemidiaphragmatic paralysis (DP).ObjectivesThis study compares ultrasound-guided interscalene brachial plexus block (USG-ISB) with a combination of ultrasound-guided pericapsular nerve block (USG-PENB) and superficial cervical plexus block (SCPB) to evaluate analgesic efficacy and the incidence of DP.MethodsIn this prospective, triple-blinded randomized trial, 42 American Society of Anesthesiologists (ASA) I - II patients undergoing elective ASS were randomized into two groups after induction of general anesthesia (GA): Group A (ISB, 10 mL 0.25% bupivacaine) or group B [pericapsular nerve block (PENB) 10 mL + SCPB 5 mL 0.25% bupivacaine]. Blocks were performed under ultrasound guidance. The primary outcome was the incidence of DP; secondary outcomes included pain scores, opioid consumption, pulmonary function, and patient satisfaction.ResultsCompared with group A, group B demonstrated a delayed time to first request for rescue analgesia (13.24 vs. 8.38 hours; P < 0.001) and reduced 24-hour fentanyl consumption (135.71 vs. 192.86 mcg; P = 0.012). Pulmonary function was significantly better preserved in group B (P < 0.05). The incidence of DP was lower in group B (4.76% vs. 38.1%; P = 0.02). Pain scores at 6, 12, and 18 hours were also lower in group B (P < 0.05). Both groups showed no differences in hypotension, bradycardia, or patient satisfaction.ConclusionsThe combination of PENB and SCPB provides analgesia non-inferior to ISB, while significantly reducing the incidence of DP and opioid requirements. For individuals at risk of respiratory impairment, this approach presents a lower-risk alternative without compromising pain control efficacy.

Nicotine has been investigated in prior studies for its analgesic effects and its impact on postoperative nausea and vomiting (PONV), yet results have been inconsistent. This systematic review and narrative synthesis evaluates the effects of perioperative nicotine administration on postoperative pain control and PONV in patients undergoing general anesthesia. A systematic literature review was conducted, and findings were summarized narratively. Comprehensive searches were performed in PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar for studies published between 2004 and 2023, using a PICO-based approach. The PICO criteria included: Patients undergoing general anesthesia, perioperative nicotine as the intervention, placebo or no nicotine as the comparator, and pain scores as the primary outcome. The Mendeley application was utilized to eliminate duplicate data. Title, abstract, and full-text screenings were independently conducted by all authors using the online review platform Rayyan. Final data were individually extracted into Excel spreadsheets. The risk of bias in the included studies was assessed with the Cochrane Risk of Bias 2 (RoB 2) tool. Eleven studies encompassing 753 participants (384 receiving nicotine, 369 controls) were included. Of these, 514 were female and 239 were male, all having undergone different surgical procedures and receiving nicotine via various methods and dosage forms. The majority of participants were nonsmokers. Primary outcomes across the studies predominantly involved postoperative pain scores, while secondary outcomes included the incidence of PONV, antiemetic requirements, and opioid consumption. No additional analyses were performed due to heterogeneity among the included studies. Although perioperative nicotine administration demonstrated reductions in postoperative pain, nausea, vomiting, and opioid consumption in some studies, the effect of nicotine on PONV was inconsistent. Variability in patient populations, dosage forms, and dosages complicates the formulation of definitive clinical recommendations. Overall, perioperative nicotine shows promise for improving postoperative pain management, but its impact on PONV requires careful consideration. Nicotine administration has been investigated as an analgesic adjunct and as a strategy for preventing PONV. This systematic review aimed to determine the effect of perioperative nicotine administration on postoperative pain and PONV.

BackgroundShoulder pain is widely recognized as one of the most prevalent complications following cholecystectomy procedures. The management of postoperative shoulder discomfort primarily relies on pharmacological interventions. Pregabalin, a commonly prescribed medication, is valued for its efficacy in modulating neuropathic pain.ObjectivesThis study aimed to evaluate the impact of preoperative pregabalin, in combination with paracetamol, on the control of shoulder pain after cholecystectomy.MethodsThis randomized, double-blind clinical trial enrolled 90 patients aged 20 - 60 years, scheduled for cholecystectomy at Imam Ali Hospital in Bojnourd in 2023. Patients were selected by convenience sampling and randomly assigned to one of three groups. The first group received 300 mg of oral pregabalin one hour before surgery, as well as 1 g of intravenous paracetamol 30 minutes before the end of the operation, followed by dosing every 6 hours for 24 hours. The second group received only oral pregabalin as premedication one hour prior to surgery. The third group received standard care (standard multimodal analgesia with diclofenac as needed), without pregabalin or paracetamol. The primary outcome was the severity of shoulder pain during recovery and at 6, 12, 18, and 24 hours postoperatively, measured using the Visual Analog Scale (VAS).ResultsSignificant differences were observed in the severity of postoperative shoulder pain among the three groups at all-time intervals (P < 0.05). Inter-group comparisons revealed that the severity of shoulder pain in the first group was significantly lower than in the third group at all-time points (P < 0.05). Additionally, the second group exhibited significantly lower shoulder pain severity compared to the third group at all-time points except at 18 and 24 hours postoperatively (P < 0.05). There was a notable reduction in pain severity over time in the first and second groups (P < 0.001).ConclusionsAccording to the study findings, premedication with oral pregabalin and intravenous paracetamol effectively alleviated postoperative shoulder pain across all time intervals without adverse effects. Pregabalin premedication alone also demonstrated analgesic effects, though with a shorter duration compared to the combination regimen.

IntroductionPostoperative cerebrospinal fluid (CSF) leak is an uncommon but clinically important complication of lumbar spine surgery, typically presenting with orthostatic headache. When conservative management and dural repair are unsuccessful, image-guided interventions may be required.Case PresentationWe report a 48-year-old woman who developed a refractory CSF leak with disabling orthostatic headache following multilevel lumbar decompression. Despite initial conservative management and revision dural repair, symptoms persisted. Heavily T2-weighted magnetic resonance myelography (HT2W-MRM) localized the leak to the L4-L5 level. Conventional approaches such as re-exploration, lumbar drainage, or standard lumbar epidural blood patch (EBP) were relatively contraindicated because extensive postoperative fibrosis, adhesions, and altered epidural anatomy rendered direct lumbar access unsafe and technically impractical. The main intra-procedural challenges included navigating through scarred epidural planes and ensuring precise blood delivery to the leak site without risking additional dural trauma. Given the presence of postoperative fibrosis and technical inaccessibility via standard lumbar approaches, a fluoroscopy-guided caudal epidural blood patch (CEBP) was performed. A flexible epidural catheter was inserted through the sacral hiatus and advanced under real-time fluoroscopy to the identified leak site. Twenty milliliters of autologous blood were injected incrementally into the posterior epidural space. The patient experienced complete resolution of orthostatic headache and cessation of CSF leakage within 24 hours. At both two-week and two-month follow-up visits, she remained symptom-free, with no neurological deficits or recurrence. No procedural complications were observed.ConclusionsThis case highlights the feasibility, safety, and clinical efficacy of catheter-guided CEBP performed under fluoroscopic guidance for treating complex, refractory CSF leaks in the early postoperative period. Importantly, it is one of the first reports to demonstrate this approach immediately following failed surgical dural repair, a scenario rarely documented in the literature. By integrating high-resolution MR myelography with precise catheter navigation, targeted therapy can be delivered effectively in anatomically altered spines where conventional techniques are contraindicated. Thus, this case uniquely illustrates how catheter-guided caudal access can serve as a novel, minimally invasive option in the early postoperative setting when direct lumbar access is no longer feasible.

BackgroundFailed back surgery syndrome (FBSS) is a challenging chronic pain condition following spinal surgery, often resistant to conventional therapies. Caudal epidural injection is a mainstay for managing FBSS, yet its effects on intracranial pressure (ICP), particularly in adults with post-surgical anatomical changes, remain poorly understood. Optic nerve sheath diameter (ONSD) measured by ultrasound offers a non-invasive surrogate marker for detecting alterations in ICP.MethodsThis prospective single-center clinical trial enrolled 46 adult FBSS patients scheduled for therapeutic caudal epidural injection at Imam Hussein Hospital, Tehran, Iran. Each participant received a standardized two-stage, 30 mL caudal epidural injection. The ONSD and hemodynamic parameters [systolic, diastolic and mean arterial blood pressure (SBP), (DBP), (MAP), heart rate (HR)] were assessed at baseline, immediately, and then at 10, 20, and 40 minutes post-injection. All measurements were performed by blinded, trained personnel using validated protocols.ResultsCaudal epidural injection produced a significant, transient increase in mean ONSD (baseline: 4.8 ± 0.49 mm; immediate post-injection: 5.1 ± 0.50 mm; P < 0.001), which normalized within the observation period. No patient exhibited symptoms or clinical signs of raised ICP. While serial monitoring indicated statistically significant reductions in SBP, DBP, MAP, and HR at 40 minutes, all values remained within physiologically acceptable ranges. No major procedural complications or adverse neurological outcomes occurred.ConclusionsStandard-volume caudal epidural injection in adults with FBSS causes a temporary, asymptomatic elevation in ONSD, reflecting a reversible change in ICP. The procedure was well tolerated, with minimal and clinically insignificant hemodynamic effects, supporting its safety and utility in this patient population.

Regional anesthesia techniques have gained popularity for lower limb (LL) surgeries. The psoas compartment block (PCB)-sciatic nerve block (SNB) combination effectively anesthetizes the entire lower extremities while providing greater hemodynamic stability. The combined lumbosacral erector spinae plane block (LS-ESPB) has shown promise in providing effective analgesia for various surgical procedures by targeting both the lumbar and sacral regions. This investigation compared the outcomes of the LS-ESPB and the PCB combined with the SNB for unilateral LL anesthesia. This randomized open-label study involved 130 critically ill patients, of both sexes, aged 18 - 65 years, undergoing unilateral LL operations. Participants were randomized equally into two groups. Group A received ultrasound (US)-guided lumbar erector peripheral nerve block (LESPB, 20 mL) and sacral erector peripheral nerve block (SESPB, 40 mL), and group B received US-guided PCB (20 mL) combined with SNB (20 mL). Both groups received blocks of 0.25% bupivacaine. The incidence of success was significantly higher in group A compared to group B (90.77% vs. 76.92%, P = 0.032). Intraoperative heart rate (HR) and mean arterial blood pressure (at 30 and 45 min), pain scores (at 6h), and total morphine consumption within the first 24 hours were significantly lower in group A compared to group B (P < 0.05). The time to the first request for rescue analgesia was significantly prolonged in group A compared to group B (P < 0.001). Side effects were similar within the studied groups. Patient satisfaction was considerably higher in group A compared to group B (P = 0.020). The LS-ESPB is more effective than the PCB-SNB combination for unilateral LL surgeries, offering a higher incidence of success, more stable hemodynamics, better analgesia, and higher patient satisfaction, with similar side effects.