Manner of Death and Fentanyl Related Drug Overdose Trends in Marion County, Indiana, US from 2018 to 2021

The purpose of this research was to investigate the manner of deaths in Marion County, throughout the years of 2018 to 2021 to see if there were any correlative increases in homicide, suicide, natural, accidental, or drug overdose related deaths. We surveyed the incidence of all deaths that occurred from 2018 through 2021 which came through the Marion County Coroner’s Office, Indiana. The data was then divided into two halves. According to the data, the leading manner of death in the first half and second half was accidental. This study revealed a total of 8732 cases: 3817 of them were observed to be accidental, 3092 natural, 956 homicide, 689 suicide, and 178 were undetermined. There were initially 318 drug overdose related deaths in 2018 and they increased to 2163 by 2021. In 2018, the number of deaths due to fentanyl related overdoses increased from 195 to 799 in 2021. This research will contribute to the forensic science field by providing information about the manner of death and fentanyl trends in Marion County over the last four years.

Neonatal Cord Tox Panel and Maternal Perinatal Fentanyl Exposure: A Retrospective Chart Review

Objective: The specific aim of this study was to determine if the currently available cutoff for fentanyl in umbilical cord (UC) was appropriate to distinguish illicit fentanyl exposure from therapeutic in-hospital administration of fentanyl. Study Design: Medical record review was conducted for perinatal administration of fentanyl and the detection of fentanyl in the corresponding routine UC toxicology. Specimens were initially tested with immunoassay followed by mass spectrometry (n = 62). Result: Excluding a single specimen that was confirmed positive, specimens were below the assays’ limit of quantification. The immunoassay’s mean b/b0 for the cases that received and did not receive fentanyl prior to delivery was 91.3% ± 10.6% and 98.2% ± 6.5%, respectively (p = 0.003). Conclusion: We demonstrated that UC is a suitable specimen type for the detection of fentanyl and that the cutoff selected adequately identifies illicit fentanyl use while not flagging cases where fentanyl was administered by the hospital prior to birth.

4-取代Fentanyl类化合物电子结构及构效关系研究

本文对十一个4-取代Fentanyl类化合物进行了量子化学(INDO)计算,研究了它们的电子结构及构效关系.结果表明,这些化合物同其他Fentanyl类化合物在主要活性部位和电子结构趋势上基本相同.酰胺氧原子是最重要的负电中心,哌啶氮原子在季铵化后发挥正电中心作用.4-取代基的极性基团可能以电荷转移作用或氢键接受体形式与受体极性部位结合,并能影响其他活性部位电子密度,另外,4-取代基的立体因素与疏水因素同生物活性相关.

Using Umbilical Cord Tissue to Identify Prenatal Exposure to Fentanyl and Other Commonly Abused Drugs

Background: Prenatal exposure to fentanyl may lead to Neonatal Abstinence Syndrome (NAS), a constellation of symptoms observed when newborns begin withdrawing from addictive substances such as opioids. The use of umbilical cord tissue segments (UC) for newborn toxicology has been increasing due to its apparent long detection window, sensitivity, and ease of collection. However, very little has been reported in the literature concerning the prevalence of in utero exposure to fentanyl and co-exposure with other commonly abused substances. Specific aim: The specific aims of this retrospective study are twofold. We will report prevalence of neonatal exposure to fentanyl for a nationwide high-risk population using UC submitted to a national reference laboratory for routine forensic toxicology analysis and the co-exposure patterns observed for these fentanyl-exposed neonates. Methods: A secondary analysis was performed using historical data for UC received between January 1, 2020 and December 31, 2020 for routine forensic toxicology analysis. Results: During the study period, our laboratory received 23,104 UC for analysis and 9667 (41.8%) of those UC were positive for at least one drug. The prevalence of fentanyl detection was 1.9% (n = 429). Of these 429 specimens there were 407 UC where both fentanyl and norfentanyl were detected. There were 14 UC where only fentanyl was detected and 8 UC where only norfentanyl was detected. When detected, the median concentrations of fentanyl and norfentanyl were 4029 pg/g (IQR: 1696, 9230 pg/g) and 10,756 pg/mg (IQR: 3925, 25,288 pg/g), respectively. Of the 429 positive fentanyl and/or norfentanyl UC, 33 (7.7%) were only positive for fentanyl and/or norfentanyl. Of the 396 polypositive UC, morphine was the highest co-exposure with 243 UC (56.6%) being positive for both fentanyls and morphine. The second most prevalent co-exposure observed was methamphetamine/amphetamine (n = 173;40.3%) followed by cannabinoids (n = 113;26.3%) and benzoylecgonine (cocaine metabolite;n = 106;24.7%). Conclusions: Nonmedical use of fentanyl is an alarming trend in this country including this maternal demographic reported here. Fentanyl was typically found with other commonly abused substances.

Multicenter Clinical Study for Evaluation of Efficacy and Safety of Transdermal Fentanyl Matrix Patch in Treatment of Moderate to Severe Cancer Pain in 474 Chinese Cancer Patients

Objective: Although a new matrix formulation fentanyl has been used throughout the world for cancer pain management, few data about its efficacy and clinical outcomes associated with its use in Chinese patients have been obtained. This study aimed to assess the efficacy and safety of the new system in Chinese patients with moderate to severe cancer pain. Methods: A total of 474 patients with moderate to severe cancer pain were enrolled in this study and were treated with the new transdermal fentanyl matrix patch (TDF) up to 2 weeks. All the patients were asked to record pain intensity, side effects, quality of life (QOL), adherence and global satisfaction. The initial dose of fentanyl was 25 ?g/h titrated with opioid or according to National Comprehensive Cancer Network (NCCN) guidelines. Transdermal fentanyl was changed every three days. Results: After 2 weeks. The mean pain intensity of the 459 evaluated patients decreased significantly from 5.63?1.26 to 2.03?1.46 (P<0.0001). The total remission rate was 91.29%, of which moderate remission rate 53.16%, obvious remission rate 25.49% and complete remission rate 12.64%. The rate of adverse events was 33.75%, 18.78% of which were moderate and 3.80% were severe. The most frequent adverse events were constipation and nausea. No fatal events were observed. The quality of life was remarkably improved after the treatment (P<0.0001). Conclusion: The new TDF is effective and safe in treating patients with moderate to severe cancer pain, and can significantly improve the quality of life.

Membrane Separator Interface for Mass-Spectrometric Analysis of Desflurane, Propofol and Fentanyl in Plasma and Cerebrospinal Fluid

Mass-spectrometric interface for the measurement of anaesthetic agent concentration in biological fluids (blood plasma and cerebrospinal fluid) is described. Sampling of biological fluids was performed during balanced inhalational (desflurane, fentanyl) anaesthesia and total intravenous (propofol, fentanyl) anaesthesia. The described method for drug concentration measurement in biologic fluids does not require long-term sample processing before injecting the sample into mass-spectrometer interface, in contrast to chromatographic methods. A hydrophobic membrane was used in the interface to separate anaesthetic agents from biological fluids: inhalational anaesthetic desflurane, hypnotic propofol, analgesic fentanyl. A possibility to use the interface for measurement of desflurane and propofol absolute concentration in blood plasma and cerebrospinal fluid was demonstrated for the study of blood-brain barrier (BBB) properties.

Effects of Dexamethasone, Clonidine, Tramadol and Nalbuphine on Fentanyl-Induced Hyperalgesia in Rats

Opioids are drugs used to alleviate pain. However, studies have demonstrated that these drugs can cause an increase in pain sensitivity, which is called opioid-induced hyperalgesia. The objective of this study was to describe the effects of dexamethasone, clonidine, tramadol and nalbuphine on fentanyl-induced hyperalgesia in rats. After obtaining approval from the Committee for the Ethical Use of Animals (CEUA), 36 male Wistar rats were divided into 6 groups: Group 1 (GCSSL) wherein the rats received 1 ml 0.9% saline solution in two injections;Group 2 (GFTSL), received fentanyl at a dose of 100 ug·kg-1 followed by 1 ml 0.9% saline solution via intraperitoneal;the remaining groups (3, 4, 5, 6) received fentanyl at a dose of 100 ug·kg-1 following doses via intraperitoneal: Group 3 (GFTDX), dexamethasone at a dose of 1.0 mg·kg-1;Group 4 (GFTCL), clonidine at a dose of 20 mg·kg-1;Group 5 (GFTTR), tramadol at a dose of 50 mg·kg-1, and Group 6 (GFTNB), nalbuphine at a dose of 5 mg·kg-1. Under general anestesia using isoflurane, the animals were submitted to a surgical incision. Hyperalgesia was evaluated by applying Von Frey filaments at 2 hours after the incision and on the 1st, 3rd and 5th days afterward. At 2 hours after the surgical procedure, there was lower intensity of pain in the fentanyl group (GFTSL) compared to the other groups, and on the fifth day there were no significant differences for pain intensity between groups. The results suggest the presence of fentanyl-induced hyperalgesia and efficacy in its reduction by dexamethasone, clonidine, tramadol and nalbuphine.

ADSORPTIVE STRIPPING VOLTAMMETRY OF A FENTANYL DERIVATIVE DNPME AT Hg ELECTRODE

A quasi-reversible reduction peak of a fentanyl derivative DNPME is found by cyclic voltammetry at Hg electrode. Epc=-1.58 V （vs. Ag/AgCl）. The cathodic peak shows adsorptive characteristics. The adsorbed species is DNPME neutral molecule. The method for measuring trace amount of DNPME by adsorptive stripping voltammetry is established.

Effects of Ketoprofen, Ketamine, Lidocaine and Propofol on Fentanyl-Induced Hyperalgesia in Rats

Opioid-induced hyperalgesia negatively affects physiological pain management and presents a complex causal mechanism, involving, pharmacodynamic and pharmacokinetic factors of interactions with receptors, opioid-independent ascending systems and with pro-nociceptive systems. After approval by the CEUA, 42 male Wistar rats were divided into 7 groups: In group 1 (GCSSL) the animals received 1 ml of 0.9% saline solution intraperitoneally (IP);in group 2 (GFTSL), they received fentanyl at a dose of 100 ug·kg-1 IP;in the remaining groups (3, 4, 5, 6 and 7) the animals received IP, fentanyl at a dose of 100 ug·kg-1 followed also by IP route of: group 3 (GFTKP) ketoprofen at a dose of 5 mg·kg-1;group 4 GFTKT), ketamine up to a dose of 10.0 mg·kg-1;group 5 (GFTLI), incisional lidocaine up to a dose of 10 mg·kg-1;group 6 (GFTLP), intraperitoneal lidocaine up to a dose of 10 mg·kg-1 and group 7 (GFTPP), propofol up to a dose of 60 mg·kg-1. Under general anesthesia, all animals with a plantar surgical incision. Hyperalgesia was evaluated by applying Von Frey filaments on the 2nd, 1st, 3rd and 5th days after treatment. In the 2nd hour and on the 5th day after the procedure, there was no hyperalgesia associated with the use of fentanyl, however, on the 1st and 3rd postoperative days there was hyperalgesia that was attenuated by ketoprofen, ketamine, lidocaine infiltrated in the incision and intraperitoneally, an effect not observed with the use of propofol. The results suggest fentanyl-induced hyperalgesia and the efficacy of ketoprofen, ketamine, incisional lidocaine and intraperitoneal lidocaine in reducing this effect.

Effects on newborns of applying bupivacaine combined with different doses of fentanyl for cesarean section

BACKGROUND The choice of anesthesia for cesarean section is very important.AIM To compare the effects of applying bupivacaine combined with different doses of fentanyl on newborns after cesarean section.METHODS We randomly divided one hundred and twenty patients undergoing cesarean section into the following 4 groups:group B(bupivacaine group),group BF10(bupivacaine combined with 10μg fentanyl),group BF30(bupivacaine combined with 30μg fentanyl)and group BF50(bupivacaine combined with 50μg fentanyl).The heart rate,mean arterial pressure,block plane fixation time and sensory block time were recorded.Umbilical artery blood was then collected immediately after fetal delivery for blood gas analysis and qualitative detection of fentanyl.Additionally,data on the neonatal 1-min and 5-min Apgar scores,results of umbilical artery blood gas analysis and qualitative detection of fentanyl in umbilical artery blood were recorded.RESULTS Although the mean arterial pressure decreased in all four groups at 3 min after anesthesia,the percentage of the decrease was less than 20%of the baseline.In addition,there were no significant differences in the 1-min or 5-min Apgar scores or the umbilical artery blood gas analysis among the four groups(P>0.05).Moreover,the concentration of fentanyl in umbilical artery blood was qualitatively detected using an ELISA kit,and the results in the four groups were negative.CONCLUSION Bupivacaine combined with fentanyl spinal anesthesia is effective in cesarean section.

Comparison of impact of adjuvant treatment of midazolam, fentanyl, and magnesium sulfate with intrathecal bupivacaine on block characteristics and postoperative analgesia in knee arthroplasty: A randomized clinical trial

Objective:To compare the efficacy of midazolam,fentanyl,and magnesium sulfate as adjuvants to intrathecal bupivacaine on both block characteristics and postoperative analgesia in knee arthroplasty.Methods:This randomized double-blind clinical trial recruited spinal anesthesia patients of the American Society of Anesthesiologists classⅠorⅡ,who needed knee arthroplasty.Patients were stratified into three intervention groups,including the midazolam group,the fentanyl group,and the magnesium sulfate group,and the patients were administered with midazolam,fentanyl,and magnesium sulfate,respectively.Hemodynamic parameters,sensory and motor block,and pain score(Visual Analogue Scale)were measured and compared among the three groups.Results:A total of 105 patients were included in this study with 35 patients in each group.There was no statistically significant difference in terms of oxygen saturation,mean blood pressure,duration of surgery,and postoperative complications,including nausea,vomiting,bradycardia,dizziness,and hypotension,as well as the time of opioid administration among the three groups(P>0.05).Statistically significant differences were found in terms of heart rate at 15,30,45,60,75,and 105 min after beginning of operation among the three groups,which was lower in the midazolam group(P<0.05).The midazolam group showed a shorter time to achieve sensory block after spinal anesthesia,sensory block to T8 or higher and sensory block to T12 and L1(P<0.05).Besides,the three groups showed significantly differences in terms of onset of motor block after spinal anesthesia and time to achieve motor block to T8 or higher or Bromage score 3(P=0.001).No significant difference was noted in pain scores among the three groups(P>0.05).Conclusion:Midazolam resulted in a shorter time to achieve sensory and motor block to T8 or higher,the onset of motor block and sensory block after spinal anesthesia,and time to achieve sensory block to T12 and L1,and the pain scores were not significantly different among the groups.Thus,midazolam can be highly underlined,if a shorter onset of sensory and motor blocks is targeted.[Funded by the research deputy of Arak University of Medical Sciences(No.99258);fa.irct.ir number,IRCT20141209020258N164].

No relationship between the incidence of fentanyl-induced cough and smoking

The purpose of the study was to investigate whether or not the incidence of cough after intra-venous fentanyl depends on the patient’s smoking state and the speed of injection. 530 ASA class I-III patients free of bronchial hyperreactivity and res-piratory tract infection undergoing general anes-thesia for elective surgery were randomized to 1.5 g.kg-1 fentanyl injected over 2, 5 or 10 sec or pla-cebo via a peripheral intravenous cannula. The endpoint was cough within 5 min after completion of injection. Statistical evaluation was performed by factorial ANOVA and chi-square-test. Assuming around 25% smokers in our patient population calculated patient sample size was 340 per group. The study was terminated for futility after enrol-ment of 530 patients since an interims analysis yielded an incidence of cough of 2 % both in smokers (n=174) and nonsmokers (n=356, p= 0,970), which was unrelated to the speed of injec-tion and not different from placebo.

Inhibitory Effect of Fentanyl on Phenylephrine-Induced Contraction on Rabbit Aorta

This in vitro study was designed to assess the effects of fentanyl on isolated rabbit thoracic aorta rings contracted with phenylephrine. Methods included contraction of aorta rings with phenylephrine (10–5 M) and recording the changes after increasing concentrations of fentanyl (10–9 M – 10–5 M). Similar experiments were done after incubation with Nω- nitro-L-arginine methyl ester (10–4 M), indomethacin (10-5 M), naloxone (10–5 M), ouabain (10–5 M), TEA (10–4 M) and glibenclamide (10–5 M). It was revealed that, fentanyl causes relaxation in rabbit aorta rings precontracted with phenylephrine. Removal of endothelium significantly reduces the relaxant response to fentanyl. Nitric oxide synthase inhibitor L-NAME, K+ channel blocker glibenclamide and Na+/K+ ATPase inhibitor ouabain inhibits the relaxant effect of fentanyl in endothelium intact aorta rings. These results suggest that fentanyl causes dose dependent vasodilatation in the rabbit aorta via activation of KATP channels and Na+-K+ -ATPase, and nitric oxide released from endothelium.

Outcome Values of Adding Sodium Bicarbonate, Dexamethasone and Fentanyl to Local Anesthetic in Peribulbar Block during Vitreoretinal Surgeries. A Randomized Prospective Study

Background and aims: we aimed to detect the outcome values of adding fentanyl, dexamethasone and sodium bicarbonate to mixture of local anesthetic in peribulbar block for vitreoretinal surgery. Methods: 120 adult ASA I & II patients, admitted for vitreoretinal surgery under peribulbar block were included in this comparative study. This study included 4 groups: Group I: (30) patients using a mixture of 1 ml normal saline, 4 ml lidocaine 2% plus 4 ml from bupivacaine 0.5% 20 ml vial containing hyaluronidase 1500 IU. Group II: (30) patients using a mixture of 1 ml of sodium bicarbonate (from 1 ml sodium bicarbonate 8.4% diluted in 10 ml normal saline), 4 ml lidocaine 2% plus 4 ml from bupivacaine 0.5% 20 ml vial containing hyaluronidase 1500 IU. Group III: (30) patients using a mixture of 1 ml fentanyl 20 μg (from a mixture of fentanyl 100 μg diluted in 5 ml normal saline), 4 ml lidocaine 2% plus 4 ml from bupivacaine 0.5% 20 ml vial containing hyaluronidase 1500 IU. Group IV: (30) patients using a mixture of 1 ml of 4 mg dexamethasone (1 ampoule = 8 mg/2 ml), 4 ml lidocaine 2% plus 4 ml from bupivacaine 0.5% 20 ml vial containing hyaluronidase 1500 IU. We measured the onset and duration of anesthesia, IOP, eyelid and global akinesia, postoperative pain by numerical pain rating scale, first analgesic requirement and postoperative side effects. Results: No significant differences were detected among the four groups as respect to age, sex and the intraocular pressure (IOP) before the anesthesia block. While the intraocular pressure (IOP) after the anesthesia block there was a significant difference, as IOP was markedly decreased postoperatively in group II compared with other groups. As regard to the onset & duration of anesthesia there was significant difference among all groups, there was rapid onset and prolonged duration of anesthesia in group III compared with other groups (1.77 ± 0.63 & 5.03 ± 0.89) respectively. As regard the onset of lid akinesia there was significant difference among the four groups with better outcome in group III, as in group III represented the most rapid onset of lid akinesia. As respecting to the onset of global akinesia there was significant difference among the four groups. There was better outcome in group III as it represented more rapid onset of global akinesia compared with other groups. There were significant differences among the four groups as regard postoperative pain all over 6 hours, better results were in group III (0.27 ± 0.69) compared with group I (2.23 ± 1.17), group II (2.00 ± 1.70), group IV (0.67 ± 0.71). As regarding to the first time for analgesic requirement there were significant differences among groups, there was no request for analgesia with better outcome in group III with increasing need to the analgesic medication in group I compared to group II and group IV. As regard side effects postoperatively there were few side effects in all groups with few numbers of cases in groups III only one patient. Although these differences in number of patients are not significant among the four groups. Conclusion: Addition of sodium bicarbonate to local anesthetic mixture was the best way in lowering the IOP other than other groups and addition of fentanyl to local anesthesia provided more rapid onset and duration of anesthesia, more rapid onset and duration for lid and global akinesia, less pain, less analgesic requirement and minimal side effects than the other groups.

A Comparative Study between Dexmedetomidine versus Fentanyl on Intubating Conditions and Side Effects during Awake Fiberoptic Nasal Intubation under Topical Anesthesia in Patients Underwent Elective Surgical Operation

Awake fiber optic intubation is the gold standard technique for management of anticipated difficult airway. In spite of availability of several sedatives, at higher doses these drugs cause respiratory depression and sensorium. This study was conducted to evaluate and compare the efficacy of Dexmedetomidine or Fentanyl for sedation during AFOI. Sixty patients, aged 20 - 40 years undergoing AFOI were made into two groups, group D Dexmedetomidine 1 mcg/kg, and group F Fentanyl 2 μg/kg, both drugs was diluted with 50 ml saline to be infused over 10 minutes). Demographic data, patient cough score, sedation score and post-intubation score were compared between two groups. Cough score ≤ 2 was 25 patients in group D compared with 2 patients in group F, post intubation score 1 in group D was 24 vs. 2 in group F, mean Ramsy sedation score in group D was 3 vs. 2.1 in group F, SpO2 ≥ 95% in group D was 28 vs. 5 patients in group F, insignificant rise in MAP from 93 to 96 mmhg in group D (P = 0.347), but there was significant rise from 92.3 to 118.18 (P ≤ 0.0001) in group F, there was significant decrease in HR from 77.4 to 71 (P = 0.005) vs. significant rise from 77 to 114 (P ≤ 0.0001) in group F. Thus, we can conclude that Dexmedetomidine provides better intubating condition, sedation, less respiratory depression and hemodynamic stability than fentanyl for AFOI, without adversely affecting airway.

A Comparative Study between Intravenous Fentanyl and Intravenous Lidocaine on Attenuation of Hemodynamic Pressor Responses to Laryngoscopic Intubation: A Prospective Cohort Study, Ethiopia

Introduction: Laryngoscopic intubation is an insertion of endotracheal tube into the trachea for maintenance of airway during general anesthesia. Smooth intubation requires attenuation of pressor responses and maintenance of baseline hemodynamic stability. The primary outcome of this study is to compare intravenous fentanyl and lidocaine as an anesthetics adjuvant on attenuation of hemodynamic pressor responses to Laryngoscopic intubation in elective surgical adult patients. Methods: This prospective cohort study recruits 114 patients who underwent elective surgery under general anesthesia with laryngoscopy and endotracheal tube intubation. The study was conducted from January 1, 2018 to March 30, 2018. Systemic random sampling technique was used to select the study participants. Those patients that received intravenous fentanyl 2 micrograms per kilogram three minutes before intubation as an anesthetics adjuvant are considered as Fentanyl-group (group F). The Lidocaine-group (group L) was those patients who receive 2% intravenous lidocaine 1.5 milligrams per kilogram three minutes before intubation as anesthetics adjuvant. Hemodynamic parameters (heart rate and blood pressure) and other variables were documented starting from 3 minutes before intubation to 5 minutes after intubation. Results: The mean heart rate at first minute after intubation was significantly lower in fentanyl group (98.91 ± 15.6 beats per minute (bpm)) compared to lidocaine (107 ± 15.45 bpm), t (112) = 2.8, p = 0.006. Systolic blood pressure was also significantly lower in fentanyl group (141.9 ± 18.9 millimeters of mercury (mmHg)) compared to lidocaine (150 ± 18.098 mmHg), t (112) = 2.45, p = 0.016 at first minute after intubation. At third minute after intubation, heart rate was significantly lower in fentanyl group compared to lidocaine, t (112), p = 0.037. No difference was in heart rate and blood pressure among the group at 5th minute after intubation (p > 0.05). Conclusion and Recommendations: Fentanyl was better on attenuation of hemodynamic pressor responses to laryngoscopic intubation when compared to lidocaine. Therefore, using fentanyl pre-operatively to attenuate pressor responses especially during intubation is important.

A Comparative Study of Intrathecal Injection of Bupivacaine Alone or with Fentanyl, Clonidine, and Neostigmine in Lower Abdominal Surgeries

Background: Anesthesiologists are responsible for the development of pain services in the current era. Hence ideal adjuvants that can be used with bupivacaine for stable intraoperative conditions and prolonging the postoperative analgesia with fewer side effects are being investigated. Opioids, despite useful as adjuvants, are associated with undesirable side effects. Aim of the work: The study was done to compare analgesic efficacy and hemodynamic of intrathecal injection of bupivacaine alone or with fentanyl, clonidine, and neostigmine in lower abdominal surgeries, over the first 24 postoperative hours, in a randomized, double-blind, and clinical trial. Methods: 100 Patients were randomized into four equal groups, 25 patients in each group;Group B patients received 2.5 ml of 0.5% hyperbaric bupivacaine and 0.5 ml of normal saline. Group BF patients received 2.5 ml of 0.5% hyperbaric bupivacaine with (25 mics) of fentanyl. Group BC patients received 2.5 ml of 0.5% hyperbaric bupivacaine with 0.5 ml (75 mics) of clonidine. Group BN patients received 2.5 ml of 0.5% hyperbaric bupivacaine with 0.1 ml of neostigmine (50 mics) and 0.4 ml of normal saline. Intrathecal anesthesia was done with a recording of parameters intraoperative and the post-operative period. Each patient was assessed for hemodynamic parameters and effective analgesia in operation, and presence of complications (nausea, vomiting, sedation and pruritus) visual analogue pain score (VAS) postoperatively by a blinded investigator in the post-anesthesia care unit (PACU) and at 1, 2, 3, 4, 8 12, 18 and 24 h postoperatively. Results: The postoperative analgesia is more effective with group BC (the gold standard) than group B, group BF, and group BN. As regard complications during the study in all groups, complications as nausea, and vomiting were mainly with group BN;hypotension was primarily in group BC. Conclusion: Bupivacaine clonidine, bupivacaine neostigmine, and bupivacaine fentanyl intrathecal anesthesia produced a longer duration of postoperative analgesia after lower abdominal surgery in patients than bupivacaine alone. Bupivacaine clonidine mixture had the most extended period of analgesia, but with hypotension. So bupivacaine fentanyl mixture with moderate duration of analgesia and minimal side effects is most safe for a patient.

A Comparative Study of Uses of Ephedrine by Different Doses on Prevention of Hemodynamic Changes Accompanied with Induction of General Anesthesia through Propofol and Fentanyl without Adverse Effects

Background: Propofol and fentanyl combination are common with general anesthesia. However, hypotension and bradycardia are common during induction of anesthetic. This study aimed to compare the response of different doses of ephedrine for attenuation of the hemodynamic changes after anesthetic induction without adverse effects. Materials and Methods: This was a randomized, double-blinded, case-controlled clinical trial. One hundred and twenty adult patients were allocated into one of the four groups: receiving IV saline, ephedrine 0.05 mg/kg, 0.1 mg/kg, or 0.2 mg/kg respectively. Induction of anesthesia was done with propofol 3 mg/kg and fentanyl 1 mg/kg. Alterations in systolic and diastolic blood pressures (SBP, DBP), mean arterial pressure (MAP), and heart rate (HR) were calculated every 1 min after induction, and 2, 3, 4 and 5 min. Then, intubation was made. Results: Baseline hemodynamic variables were comparable between groups. Patients received 0.1 mg/kg, and 0.2 mg/kg had less drop in blood pressure both systolic and diastolic, MAP, and HR with no significant rise in side effects. The numbers of patients with hypotension were significantly lower in the group receiving ephedrine 0.2 mg/kg compared to other groups (P-value 0.05). Use of IV ephedrine at a dose of 0.1 mg/kg was shown to be useful for reduction of hemodynamic changes but did not eliminate the risk of blood pressure drop. Ephedrine 0.2 mg/kg was better without causing any adverse effects. We can conclude that ephedrine 0.1 mg/kg was suitable for minimizing or decreasing changes in hemodynamic at propofol-fentanyl induction but ephedrine 0.2 mg/kg was better without causing more adverse effects.

Intracranial Abscess Post Intravenous Misuse of Transdermal Fentanyl in an Immunocompetent Patient

Infections, including intracranial abscesses, are a well-known and potentially serious complication of intravenous drug abuse. There have been increasing reports of intravenous misuse of transdermal Fentanyl, with severe sequelae. Intracranial abscesses in intravenous drug users tend to involve uncommon pathogens, and may present with atypical symptoms, which can lead to delayed diagnosis and inadequate treatment. We present the case of a 28-year-old female, with a history of intravenous misuse of transdermal Fentanyl, who was found to have intracranial abscesses with Fusobacterium nucleatum and Nocardia species, causing significant vasogenic oedema and mass effect.

Adverse Effects of Morphine and Fentanyl for Stomatitis in Patients Receiving Allogeneic Hematopoietic Cell Transplantation—A Single Center Retrospective Analysis

Opioids are widely used as analgesics for oral mucositis in allogeneic hematopoietic cell transplantation (allo-HCT). Their main adverse events are nausea, vomiting, constipation, psychological symptoms, and respiratory depression. In our institute, continuous intravenous morphine was generally used until 2007, followed by intravenous fentanyl as the first-line agent because of its potential fewer adverse events. We retrospectively analyzed 99 patients who underwent allo-HCT in the University of Tsukuba Hospital from 2004 to 2009. Out of 99 patients, 64 were treated with opioids (morphine, 32 and fentanyl, 32). The attending physicians were in charge of providing stable pain control. Median age, sex, stem cell source, preparative regimen, and GVHD prophylaxis were similar in the two groups. There were no significant differences in psychological symptoms, drowsiness, nausea, and vomiting in both groups. Defecation ratio (the days having a bowel movement/the days taking opioids) was 63% and 94% in the morphine and fentanyl group, respectively (P < 0.0001). The percentage of patients who needed to use purgative drugs was 25% and 6% in the morphine and fentanyl group, respectively (P = 0.04). It is suggested that fentanyl has less adverse effects on gastrointestinal movement and is safer than morphine when used for oral mucositis in allo-HCT.