Do we use too much propofol for sedation in colonoscopy? an observational study with sedline monitor

Objectives: Propofol and midazolam are popular sedatives in colonoscopy. Our aim was to measure depth of sedation with propofol-fentanyl and midazolam-fentanyl in patients undergoing colonoscopy using a blinded electroencephalogram [EEG]-based SEDLine monitor

Design: Non-randomized, prospective, observational

Setting: Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey

Subjects: One hundred and eight adult volunteers with American Society of Anesthesiologist [ASA] class I-II-III, aged 18 - 80 years, and undergoing colonoscopy with propofol-fentanyl [Group P] or midazolam-fentanyl [Group M] -based sedation Interventions: Demographic variables, depth of sedation and recovery times were recorded

Main outcome measures: Depth of sedation was measured and recorded with an EEG-based SEDLine monitor. Patient State Index [PSI] values at colonoscope insertion, removal, and at return of verbal responsiveness after colonoscope withdrawal were documented

Results: Patients in group P were younger [p <0.0001] and had lower ASA scores [p = 0.02] than group M patients. Group P patients experienced signi.cantly deeper degrees of sedation at all times and longer sedation and recovery times [p <0.0001 and p = 0.01]. Group P patients were more deeply sedated and had lower PSI values at the 5th minute [p <0.0001] and lower PSI scores after recovery [p <0.0001]. Group M had more comorbidity but more stable PSI values. Their sedation levels were also closer to normal

Conclusion: Clinical signs for sedation showed that propofol was over-used. The titration of propofol using a processed-EEG monitor, such as SEDLine, can improve sedation procedures by reducing time spent in states of deep sedation/general anesthesia while maintaining the clinical advantages of propofol

Various clinical conditions can mimic Crimean-Congo hemorrhagic fever in pediatric patients in endemic regions

Crimean-Congo hemorrhagic fever [CCHF] is a tick-borne disease with high mortality. Many disorders can mimic CCHF. It is important to recognize the condition and to perform differential diagnosis in endemic countries. Twenty-one children aged 18 years or less with a preliminary diagnosis of CCHF were retrospectively evaluated. Real-time PCR and a confirmatory indirect immunofluorescence assay for negative results were performed. The diagnoses determined that 9 patients had [42.9%] CCHF; 7 patients had [33.3%] viral upper respiratory tract infections [URTI]; 2 patients had [9.5%] brucellosis; 1 patients had [4.7%] periodic fever, aphthous stomatitis, pharyngitis, and adenitis [PFAPA] syndrome episode; 1 patient had [4.7%] cerebral palsy, diabetes insipidus, acute gastroenteritis, and hypernatremic dehydration; and 1 patient had [4.7%] cellulitis after a tick bite. The mean age of patients with CCHF was greater than that of the other patients [116.1 +/- 53.6 vs. 94.1 +/- 52.1 months, p = 0.02]. Seventeen [81%] of the children included had a history of tick bites, 2 [9.5%] had a history of contact with a patient with CCHF, and 2 [9.5%] had no exposure, but were living in an endemic region. Three patients had an underlying disorder: cerebral palsy and diabetes insipidus, epilepsy, or PFAPA. All of the children experienced fever. Other frequent symptoms were malaise, diarrhea, vomiting, and abdominal pain, but none of these differed statistically between the patient groups. CCHF patients had a longer mean duration of symptoms [10.56 +/- 1.42 vs. 6.75 +/- 3.62 days, p = 0.008] and a longer mean length of hospitalization [8.00 +/- 2.08 vs. 3.58 +/- 1.56 days, p < 0.001] than the other patients. At laboratory examination, patients with CCHF had statistically significant lower leukocyte and platelet counts, more prolonged coagulation parameters, and greater AST, ALT, LDH, and CK levels than the other patients. No mortality or complications occurred in the study. Both infectious causes, such as URTI, cellulitis, and brucellosis, and non-infectious causes may resemble CCHF. Although they are not pathognomonic, some indicators, including a longer symptom duration and hospitalization, cytopenia, elevated liver enzymes, creatine kinase and prolonged coagulation parameters, were found to be in favor of CCHF

Pheniramine maleate is more effective than lidocaine on fentanyl induced cough

Objective: Fentanyl is frequently used during anesthesia induction. The use of fentanyl can cause cough through different mechanisms. Here, we aimed to investigate effects of pheniramine maleate [PM], an antihistaminic agent, and compare it with lidocaine on fentanyl induced cough

Methods: This is a randomized double-blind prospective clinical study of ASA I-II, 120 patients scheduled for elective abdominal surgery. Patients were administered drugs intravenously and randomly allocated into three groups: Group C [2 ml 0.9 % normal saline], Group L [1mg/kg lidocaine], and Group F [PM 45.5 mg]. 90 seconds after administration, 2 micro/kg fentanyl was applied in three seconds to all patients. Severity of cough [mild: 1-2, moderate: 3-5, severe> 5], time of the cough and vital parameters were recorded 90 seconds after fentanyl injection

Results: Eight patients [25%] in Group C had fentanyl induced cough whereas three patients [7.5%] in Group L and one patient [2.5%] in Group F experienced this phenomenon. There was statistically significant difference between Group F and Group C [p<0.05]; however, differences between Group L and Group C or Group F and Group L were not statistically significant [p>0.05]

Conclusions: Pheniramine Maleate 45.5 mg is better that placebo and as effective as lidocaine to prevent fentanyl induced cough

Increased heart rate on first day in Intensive Care Unit is associated with increased mortality

Objective: To investigate the association of maximum HR during the first day of intensive care unit [ICU] and mortality

Methods: Data of 850 patients over 45 years of age, who were hospitalized in ICU, was retrospectively analyzed. They were divided into two groups; Group-I, patients with maximum HR<100/min Group-II, patients with maximum HR >/= 100/min on first day. The groups were compared regarding age, sex, use of beta-blockers, use of inotropic and vasopressor drugs, hemodynamic parameters, anemia, mechanical ventilation, length of hospitalization [ICU and total], mortality [ICU and total], and CHARLSON and APACHE-II scores

Results: The mean age of patients was 63 +/- 12 years and 86% were after non-cardiac surgery. Maximum HR was 83 +/- 11 in Group-I and 115 +/- 14/min in Group-II [p=0.002]. Group-II patients had more frequent vasopressor and inotropic drugs usage, [p<0.001], anemia, mechanical ventilation [p<0.005], higher CHARLSON and APACHE-II scores, stayed longer in ICU and hospital, and had higher ICU and hospital mortality compared to group-I [p<0.05]. APACHE-II scores and maximum HR<100/min were independent variables predicting ICU mortality in multivariate logistic regression analysis whereas usage of beta-blockers was not

Conclusions: Our study showed that maximum HR less than100/minute during the first day of ICU is associated with decreased mortality in Intensive Care Unit

Primary ovarian and pararectal hydatid cysts mimicking pelvic endometriosis

We report a case of 48-year-old woman with multiple hydatid cysts in pararectal region and right paraovarian localization with an unusual sonographic and computed tomographic presentation mimicking a pelvic endometriosis. During laparotomy, multiple pararectal and right ovarian cysts resembling endometriosis were resected. Pathologic examination gives the diagnosis of hydatid cysts. Retrospectively, we investigate the primary infection but the patient had no history of hepatic and liver involvement, it is a case of primary infection