Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a primary diagnostic and therapeutic option for pancreaticobiliary pathologies. Objectives: This study aimed to investigate the efficacy and safety of dexmedetomidine versus propofol during ERCP in cancer patients. Methods: This randomized controlled single-blinded trial was conducted with 202 cancer patients aged 21 to 60 years, of both sexes, with a body mass index of 18.5 to 30 kg/m2, and classified as American Society of Anesthesiologists (ASA) class II - III, who were undergoing ERCP. The patients were randomly assigned to two equal groups. The Propofol Group (n = 101) received a loading dose of propofol (1 - 2 mg/kg over 30 seconds) followed by an infusion (0.05 - 0.1 mg/kg/hour). The Dexmedetomidine Group (n = 101) received a loading dose of dexmedetomidine (1 μg/kg over 10 minutes) followed by an infusion (0.2 - 0.7 μg/kg/hour). The maintenance dose was adjusted during the procedure based on vital signs, Bispectral Index (BIS), and oxygen saturation. Results: The Dexmedetomidine group showed a significantly lower incidence of intra-procedural hypoxemic events (14.9% vs. 26.7%, P = 0.037) and a comparable incidence of hypotension (17.8% vs. 13.9%, P = 0.441). Dexmedetomidine also demonstrated significantly lower intraoperative pain scores according to the Facial Pain Score (P < 0.05), significantly lower postoperative Visual Analog Scale (VAS) scores (P < 0.05), and a lower frequency of postoperative nausea and vomiting (PONV) compared to the Propofol group. Additionally, there was a significantly higher frequency of endoscopist satisfaction in the Dexmedetomidine group compared to the Propofol group (P < 0.05). Conclusions: Dexmedetomidine can be used as a safe and effective alternative to propofol for deep sedation of cancer patients undergoing ERCP. It is associated with a lower incidence of hypoxemic events, effective intraoperative sedation, quicker recovery, and superior analgesic effects both intraoperatively and postoperatively compared to propofol.

Introduction: Post-dural puncture headache (PDPH) is a well-known consequence of neuraxial anesthesia that can impede patient recovery and delay early discharge. Traditional remedies include hydration and the administration of simple analgesics for symptom relief. When symptoms persist despite conservative interventions, an epidural blood patch (EBP) is typically recommended. However, this invasive procedure carries risks and complications. Our case report aims to explore a potential alternative treatment for PDPH. Case Presentation: We present the case of a 22-year-old female who experienced PDPH following spinal anesthesia. Despite initial attempts at conservative management, her symptoms persisted. She then opted for a trans-nasal sphenopalatine ganglion (SPG) block, which resulted in remarkable pain relief and eliminated the need for an EBP. Conclusions: The SPG block emerges as a minimally invasive option for treating PDPH. Multiple studies have demonstrated that patients undergoing SPG block therapy did not require EBP.

Background: This study compares the effects of transforaminal magnesium sulfate injection versus other methods for managing radicular back pain, highlighting its potential for improved pain relief and functional outcomes. Methods: This randomized, double-blind clinical trial involved 30 patients with radicular back pain who were randomly assigned to receive either transforaminal magnesium sulfate or triamcinolone injection. Primary outcomes were pain intensity and functional disability, assessed using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI), respectively. These were evaluated at five time points: Before the injection, 2 weeks, 1 month, 3 months, and 6 months after the injection. Secondary outcomes included drug-related adverse events within the six-month follow-up period. Results: Baseline characteristics were not significantly different between the two study groups. Compared to pre-injection measures, post-injection pain intensity and functional disability were significantly reduced in both groups at all time points (P < 0.001). At all postoperative evaluations, pain intensity and functional disability were lower in the magnesium sulfate group compared to the steroid group (P < 0.001). No drug-related side effects were recorded in either group. Conclusions: For patients with radicular back pain, transforaminal magnesium sulfate injection appears to be an effective and safe alternative to transforaminal steroid injection.

Background: Lumbar disc herniation (LDH) can cause pain in the lower back and leg, as well as numbness or weakness in the affected area. Various steroids, including methylprednisolone, are currently used for treatment. Objectives: This study aimed to compare the effectiveness of pulse intravenous infusion of 500 mg methylprednisolone with common non-steroidal anti-inflammatory drugs (NSAIDs) in relieving pain and improving the clinical condition of patients with lumbar disc herniation. Methods: This clinical trial, registered under code IRCT20211116053077N1, included an experimental group (37 patients) and a control group (35 patients). Pain assessments were conducted before treatment, and at one, two, and three weeks, as well as one and six months after treatment. The control group received common painkillers (diclofenac sodium tablets 100 mg), while the experimental group received a single dose of 500 mg methylprednisolone sodium succinate (intravenous injection in 500 cc normal saline). Pain scores were analyzed using SPSS 16 and statistical tests such as ANOVA, independent t-tests, and repeated measures ANOVA. Results: Prior to intervention, the mean (SD) pain score was 8.7 (3.57) in the experimental group and 8.17 (0.66) in the control group (P > 0.76). Six months after methylprednisolone injection, the mean (SD) pain score in the experimental group was 1.56 (0.83), compared to 6.48 (0.91) in the control group (P = 0.000). Analysis of variance indicated that methylprednisolone significantly reduced pain in patients with LDH (P = 0.000, F = 660.668). Conclusions: Given the effectiveness of intravenous pulse infusion of 500 mg methylprednisolone compared to common NSAIDs in relieving pain and improving clinical outcomes for patients with lumbar disc herniation, the use of this drug is recommended for pain reduction in these patients.

Background: One of the most prevalent causes of anterior knee pain is chondromalacia patella (CMP), particularly among young populations, including soldiers. Although various treatments have been suggested to relieve the symptoms and improve the functioning of patients with CMP, none have proven to be adequately effective. Objectives: This study assessed the effectiveness of electroacupuncture as a complementary treatment for CMP, noting its minimal complications. Methods: In this randomized clinical trial, soldiers diagnosed with CMP who met the inclusion criteria and referred to Imam Reza Hospital in Tehran in 2023 were assigned to one of two treatment groups. The electroacupuncture group received treatment at specific acupuncture points combined with an electrical current. The physical therapy group underwent treatment consisting of 10 sessions of routine physical therapy modalities. The Visual Analog Scale (VAS) for pain and disability and the knee injury and osteoarthritis outcome score (KOOS) questionnaire were used to assess the outcomes before the intervention and three months after the intervention. Results: Twenty participants were analyzed in each group. The VAS for pain and disability reduced in both groups during the study; however, the difference between the two groups was not significant (P = 0.999 for pain and P = 0.873 for disability). No significant difference was observed in the KOOS symptom score either during the study or between the two groups (P = 0.423). The changes in the “pain” scores of the KOOS questionnaire were significant both in the electroacupuncture group (P = 0.003) and in the physical therapy group (P = 0.038); however, the difference was not significant between the two groups. The “activities of daily living” scores of the patients were significant both during the study and between the two groups (P = 0.042), with a steeper improvement in the electroacupuncture group. The patients’ “sports and recreational activities” scores were significant in the electroacupuncture group (P = 0.001) and between the two groups (P = 0.023). The “knee-related quality-of-life” scores were significant in both groups, and the comparison of the two groups indicated that the slope of the changes was higher in the electroacupuncture group than in the physical therapy group (P = 0.001). Conclusions: According to the results of the current research, electroacupuncture can improve the symptoms and function of patients with CMP, and its efficacy is equivalent to that of physical therapy.

Background: Non-invasive treatment options are preferred for managing upper extremity pain due to osteoarthritis (OA). Transcutaneous pulsed radiofrequency (TcPRF) is a promising technique and appears effective in managing knee and shoulder pain. Objectives: To investigate whether TcPRF treatment is effective in reducing pain and safe to use among patients with OA of the upper extremity. Methods: In this retrospective study, patients with painful OA of the upper extremity who underwent TcPRF treatment from February 2021 to February 2022 were included. The primary outcome measure was the change in NRS pain scores between baseline and 1, 2, and 6 weeks of follow-up. Secondary outcome measures included adverse events. Data were extracted from electronic medical records and via telephone consultation after the 6-week follow-up. Results: A total of 41 initial TcPRF treatments were performed among 37 patients. The NRS score at rest showed a statistically significant improvement at 6 weeks [median = 5 [interquartile range (IQR) 2 - 8)] compared with baseline [median = 6 (IQR 4 - 8)], P = 0.023, with a moderate effect size, r = -0.44. For NRS scores during activity, all follow-up moments had lower NRS scores [median = 7 (IQR 5 - 8)] than before TcPRF [median = 8 (IQR 7 - 9)], P = 0.002 - 0.006, with moderate to large effect sizes, r = -0.45 to r = -0.51. No adverse events were reported. Conclusions: Transcutaneous pulsed radiofrequency treatment is effective in reducing pain and is safe to use among patients with upper extremity pain due to OA.

Background: Postoperative shoulder pain is one of the most common complications following laparoscopic surgery. Various interventions have been proposed to control this pain. Objectives: The main objective of this comparative study was to determine the effects of intraperitoneal bupivacaine and normal saline infusion, in combination with lung recruitment maneuver (LRM), on shoulder pain following laparoscopic surgery. Methods: The present randomized controlled trial was conducted on 105 candidates for laparoscopic cholecystectomy referred to Imam Ali Hospital in Bojnurd, Iran, from November 2021 to June 2022. The patients were assigned to three groups using block randomization: BR (receiving 50 cc of 0.25% diluted intraperitoneal bupivacaine + LRM), NR (receiving 50 cc of intraperitoneal normal saline + LRM), and N (receiving 50 cc of intraperitoneal normal saline). Postoperative shoulder pain and surgical incision site pain were assessed using the Visual Analogue Scale (VAS) at recovery intervals of 4, 12, 24, and 48 hours after surgery. Additionally, the prevalence of nausea and vomiting, the first time of need for sedation, and the incidence of sedation overdose in the first 24 hours after surgery were investigated. The data were analyzed using one-way analyzed by one-way analysis of variance (ANOVA) with SPSS software at a significance level of 0.05. Results: The findings showed no significant differences in demographic variables between the three groups. The range and mean score of shoulder pain based on VAS was 0 - 1 (0.3) in the BR group, 0 - 2 (1.4) in the NR group, and 1 - 3 (2.1) in the N group at 4 hours after surgery. The mean score of shoulder pain intensity in the BR group was lower compared to the NR and N groups during recovery time intervals at 4, 12, and 24 hours after surgery. This difference between groups was significant. There was also a statistically significant difference in the mean score of surgical incision site pain intensity and the first time of need for sedation between the three groups. The occurrence of side effects was not significant between the groups. Itching, bradycardia, and hypotension were not observed in any of the groups. Conclusions: The findings of this study showed that bupivacaine, along with LRM, is a safe method effective in relieving postoperative shoulder pain. It prolonged the first time of need for sedation and significantly reduced the incidence of shoulder pain.

Background: Otolaryngology often involves adenotonsillectomies, surgical procedures aimed at addressing obstructive sleep-disordered breathing and underlying apnea in children. Objectives: Pediatric anesthesiologists and otolaryngologists encounter challenges in managing pain post-adenotonsillectomy, especially due to the use of opioid medications in children who have an elevated baseline risk of airway obstruction and associated morbidity and mortality. Methods: This prospective, randomized, double-blinded study was conducted at Eldemerdash Hospital, Ain Shams University, Egypt, from September 2022 to August 2023. A total of 90 patients aged 5 - 13 years who underwent elective tonsillectomy surgery were randomly assigned to two groups, with 45 patients in each group. The first group, referred to as group A, received intravenous 1.0 μg/kg fentanyl, dexamethasone 150 μg/kg, and paracetamol 15 mg/kg. The second group, referred to as group B, received dexamethasone 150 μg/kg and paracetamol 15 mg/kg, with an opioid-free pterygopalatine ganglion block for multimodal anesthesia. The primary outcome measure of this study was the postoperative Wong-Baker scale at 1st, 3rd, and 24th hours. Results: This study included 90 individuals with similar demographic profiles and comparable initial characteristics and surgical techniques in both groups (P > 0.05). Intraoperative heart rate, mean blood pressure, additional analgesia, postoperative Wong-Baker scale, postoperative rescue analgesia, and laryngospasm did not show significant differences between the two groups (P > 0.05). However, there were statistically significant differences between the groups in terms of nausea, vomiting, hypoxia, and post-anesthesia care unit stay, with group B experiencing fewer of these issues (P < 0.05). Conclusions: Both conventional opioid-based multimodal anesthesia and opioid-free pterygopalatine ganglion block-based multimodal anesthesia are effective methods for providing analgesia during and after tonsillectomy surgery. The pterygopalatine ganglion block, the latter option, has been found to result in fewer postoperative complications such as nausea, vomiting, and hypoxia. Additionally, patients who receive this type of anesthesia typically require less time in the post-anesthesia care unit.

Background: One of the factors that affect the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the level of sedation. Objectives: Therefore, we aimed to compare dexmedetomidine (DEX) as moderate sedation (MS) versus general anesthesia (GA) on the diagnostic yield of EBUS-TBNA. Methods: This randomized open-label controlled trial was carried out on 70 patients older than 18 years of age, classified as American Society of Anesthesiologists (ASA) II or III, and scheduled for EBUS-TBNA. Patients were randomly allocated into two equal groups. Group D received 1 μg/kg fentanyl 2 minutes before induction with a 1 μg/kg infusion of DEX for 10 minutes, then maintenance with 0.5 - 1 μg/kg/h aiming for a Ramsey Sedation Scale of 4 - 5 while preserving hemodynamics. Group GA received 1 μg/kg fentanyl, 2 mg/kg propofol, and 0.5 mg/kg atracurium (then 0.1 mg/kg every 20 minutes). Results: Group D had a significantly higher rate of recalling the procedure (P = 0.005) and a lower rate of shortness of breath compared to group GA (P = 0.038). Intraoperative heart rate measurements at baseline were not significantly different between groups but were significantly lower at 5 min, 10 min, 15 min, 20 min, and at the end of surgery in group D compared to group GA (P < 0.05). Intraoperative mean arterial blood pressure measurements at baseline, 5 min, 10 min, 15 min, 20 min, and at the end of surgery were not significantly different between groups. Recovery time was significantly shorter in group D compared to group GA (P < 0.001). Conclusions: Compared to GA, MS with DEX showed a comparable diagnostic yield with faster recovery time and better patient satisfaction, as evidenced by a willingness to repeat procedures when needed and less shortness of breath in EBUS-TBNA.

Background: The success of epidural analgesia hinges on the precise insertion of the needle within the epidural space; failure rates have been reported to reach 32%. Objectives: We report a new method using color Doppler to help verify the accurate location of the epidural needle tip. Methods: This is a randomized prospective study. Sixty patients undergoing hysterectomy were enrolled, with 30 patients in each group. Color flow Doppler (CFD) ultrasonography was employed to guide epidural catheter placement. The ultrasound-guided epidural technique was used for patients where challenges in identifying traditional landmarks for epidural space localization were anticipated. The procedure commenced with a spinal epidural technique. After sterile preparation and draping of the area, a curvilinear ultrasound transducer, encased in a sterile sheath, was used to locate the interspinous space. The primary outcome measure focused on flow visualization at different insertion levels. Secondary outcome measures included the duration of catheter implantation, intervertebral level of insertion, and dermatome sensory levels. The study also assessed the quality of epidural analgesia and patients' assessment of analgesic quality using a Verbal Numerical Rating Scale. Results: The study reported a successful and predominantly safe outcome, with high success rates in flow visualization and effective anesthesia coverage. Flow visualization at the insertion and surrounding levels demonstrated a 100% success rate at all observed points. The Visual Numeric Rating Scale (VNRS) results indicated a median pain score of 2 with an interquartile range (IQR) of 2 - 3, showcasing a generally low level of post-procedural pain among the subjects, reflecting good quality post-operative analgesia. Regarding dermatome sensory levels after 2 hours, the distribution across various levels, including T4, T6, T7, T8, T10, and T12, exhibited a favorable outcome. The highest proportion was observed at T10 (68.3%), suggesting effective anesthesia coverage in the targeted areas. The study demonstrated comparable efficiency between the CFD-guided and blind techniques in terms of procedural aspects. However, notable distinctions were observed in patients' reported pain levels, with the CFD group experiencing lower pain compared to the blind technique group. Additionally, the study highlighted the association between CFD and improved procedural accuracy and safety. Conclusions: This study advocates for the integration of CFD into routine clinical practice to enhance procedural outcomes and patient safety during hysterectomy surgeries.