The effect of remifentanil and dexmedetomidine on dynamic thiol/disulfide balance in patients undergoing coronary artery bypass surgery: a prospective case-control study.

OBJECTIVE: It is established that the balance of serum thiols is disrupted in favor of oxidants in coronary artery disease, and the cardiopulmonary bypass pump used during coronary artery bypass surgery disrupts this balance in favor of oxidants. In this study, we investigated the antioxidant effects of remifentanil or dexmedetomidine on thiol-disulfide balance and paraoxonase-1 (PON-1) levels during on-pump coronary artery bypass surgery. PATIENTS AND METHODS: A total of 100 patients who underwent on-pump coronary artery bypass grafting surgery between May 2018 and December 2018 were included in the study. Patients were divided into two groups: the remifentanil group (Group R) and the dexmedetomidine group (Group D). Venous blood samples were obtained from the patients after induction of anesthesia [Time 1 (T-1)], then after cross-clamping of the aorta (T-2), after removal of the cross-clamp (T-3), 10 minutes after the end of protamine infusion (T-4), and 24 hours postoperatively (T-5). Serum total thiol, native thiol, disulfide, and PON-1 levels were evaluated. RESULTS: Total thiol, disulfide, PON-1, native thiol/total thiol, total thiol/disulfide, and native thiol/disulfide levels were similar between the two groups. Native thiol levels were statistically significantly higher in group D compared to group R at T-3 and T-5 (p = 0.017 and p = 0.027, respectively). When T-1 and T-5 times were compared in intragroup measurements, disulfide levels were significantly lower, and native thiol/total thiol ratios were significantly higher at T-5 (p < 0.001). CONCLUSIONS: In conclusion, in light of the data obtained from this study, it can be concluded that dexmedetomidine used during surgery has a better contribution to oxidant-antioxidant balance than remifentanil in patients undergoing coronary artery bypass surgery with the on-pump method.

Outcome at second-look laparotomy: anaesthesia related risk factors.

PURPOSE OF INVESTIGATION: To identify anaesthesia related risk factors associated with positive second-look laparotomy (SLL) findings in patients with epithelial ovarian carcinoma who had previous optimal cytoreduction surgery under general anaesthesia. METHODS: A retrospective review of the anaesthesia and medical records of patients with epithelial ovarian cancer who underwent SLL at our institution and analysis of patient related (age, haemoglobin, albumin), anaesthesia related (duration of anaesthesia, anaesthetics and dosages, transfusion of blood products), tumour related (stage, grade, presence of ascites, adhesion, histological type, capsule penetration and CA-125) data and outcome of SLL was undertaken. RESULTS: The patients had SLL 305 +/- 215 days after the first operation. Of the 83 patients 28 (33.7%) were SLL (+). SLL (+) patients were significantly more likely to have a mucinous histological subtype, required intraoperative packed red blood cell (PRBC) transfusion and longer anaesthesia duration (p < 0.05). Type of induction agent, whether narcotics were used or not, type of volatile agent used, dosages of induction agents and dosages of narcotic and muscle relaxants did not vary significantly between the patients with and without cancer recurrence (p > 0.05). Duration of anaesthesia (OR, 1.03; CI, 1-1.05, p = 0.031) and histological subtype (OR, 16.1; CI, 1.8-141.7, p = 0.012), were the independent variables predicting cancer recurrence in the multivariate logistic regression. CONCLUSION: We emphasize that duration of anaesthesia and histological subtype are risk factors for cancer recurrence in early stage ovarian carcinoma. From our data it seems that interventions to shorten the duration of general anaesthesia or reversing immunosuppression induced by anaesthesia and surgery must be carefully considered.

Three-dimensional conformal breast irradiation in the prone position

The prone position can be used for the planning of adjuvant radiotherapy after conservative breast surgery in order to deliver less irradiation to lung and cardiac tissue. In the present study, we compared the results of three-dimensional conformal radiotherapy planning for five patients irradiated in the supine and prone position. Tumor stage was T1N0M0 in four patients and T1N1M0 in one. All patients had been previously submitted to conservative breast surgery. Breast size was large in three patients and moderate in the other two. Irradiation in the prone position was performed using an immobilization foam pad with a hole cut into it to accommodate the breast so that it would hang down away from the chest wall. Dose-volume histograms showed that mean irradiation doses reaching the ipsilateral lung were 8.3 ± 3.6 Gy with the patient in the supine position and 1.4 ± 1.0 Gy with the patient in the prone position (P = 0.043). The values for the contralateral lung were 1.3 ± 0.7 and 0.3 ± 0.1 Gy (P = 0.043) and the values for cardiac tissue were 4.6 ± 1.6 and 3.0 ± 1.7 Gy (P = 0.079), respectively. Thus, the dose-volume histograms demonstrated that lung tissue irradiation was significantly lower with the patient in the prone position than in the supine position. Large-breasted women appeared to benefit most from irradiation in the prone position. Prone position breast irradiation appears to be a simple and effective alternative to the conventional supine position for patients with large breasts, since they are subjected to lower pulmonary doses which may cause less pulmonary side effects in the future

Three-dimensional conformal breast irradiation in the prone position.

The prone position can be used for the planning of adjuvant radiotherapy after conservative breast surgery in order to deliver less irradiation to lung and cardiac tissue. In the present study, we compared the results of three-dimensional conformal radiotherapy planning for five patients irradiated in the supine and prone position. Tumor stage was T1N0M0 in four patients and T1N1M0 in one. All patients had been previously submitted to conservative breast surgery. Breast size was large in three patients and moderate in the other two. Irradiation in the prone position was performed using an immobilization foam pad with a hole cut into it to accommodate the breast so that it would hang down away from the chest wall. Dose-volume histograms showed that mean irradiation doses reaching the ipsilateral lung were 8.3+/-3.6 Gy with the patient in the supine position and 1.4+/-1.0 Gy with the patient in the prone position (P = 0.043). The values for the contralateral lung were 1.3+/-0.7 and 0.3+/-0.1 Gy (P = 0.043) and the values for cardiac tissue were 4.6+/-1.6 and 3.0+/-1.7 Gy (P = 0.079), respectively. Thus, the dose-volume histograms demonstrated that lung tissue irradiation was significantly lower with the patient in the prone position than in the supine position. Large-breasted women appeared to benefit most from irradiation in the prone position. Prone position breast irradiation appears to be a simple and effective alternative to the conventional supine position for patients with large breasts, since they are subjected to lower pulmonary doses which may cause less pulmonary side effects in the future.

Use of sevoflurane during cardiopulmonary bypass decreases incidence of awareness.

BACKGROUND AND OBJECTIVE: The role of sevoflurane has not been studied in relation to awareness during anaesthesia. We observed the effect of sevoflurane on the incidence of awareness during cardiopulmonary bypass for open-heart surgery. METHODS: Fifty-nine patients of age >17 yr undergoing open-heart surgery with cardiopulmonary bypass were randomly assigned to two groups. In both groups, induction was with etomidate, dehydrobenzperidol and fentanyl; anaesthesia was maintained with sevoflurane, fentanyl and N20; vecuronium was used for muscular paralysis. Group 1 (30 patients) received dehydrobenzperidol and fentanyl during cardiopulmonary bypass; Group 2 (29 patients) received sevoflurane and fentanyl. Patients were given different auditory inputs during different phases of surgery. All patients were interviewed with standard questions 8 and 24 h postoperatively for evidence of explicit awareness. RESULTS: Five patients in the dehydrobenzperidol group gave a history of awareness (16.67%) as opposed to none in the sevoflurane group. The difference in the incidences of awareness was significant (P < 0.05), but no differences were found between the interviews conducted at 8 and 24 h. Sevoflurane and opioid combination reduced the incidence of awareness in open-heart surgery.

Paratracheal extramedullary hematopoiesis.

Extramedullary hematopoiesis (EMH) is a rare finding in hematology. A 73-year-old female patient with a 1-week history of severe progressive dyspnea was examined, and computed tomography (CT) showed a paratracheal mass 3 cm in size located 1 cm below the vocals cords and causing obliteration of the tracheal airway. Cytology of a needle biopsy revealed EMH. External radiotherapy of 200-cGy fractions to a total dose of 2000 cGy was administered with 3-dimensional conformal planning to treat the progressive symptoms. The patient's clinical symptoms started to improve 2 days after radiotherapy and had completely disappeared after 7 days. CT scans showed complete response on follow-up at 1 week to 5 months after radiotherapy. Mature and immature hematopoietic cells and many adipose cells were seen in the pretreatment samples. Histologic findings in the posttreatment samples showed that these cells had completely disappeared due to the conformal radiotherapy. On the basis of clinical, radiologic, and histologic results, we suggest that conformal radiotherapy may be useful for the treatment of paratracheal localization of EMH because good tumoral irradiation was obtained in this case, with the protection of normal tissues.

Three dimensional conformal radiotherapy in patients with T2a-b, N0, M0 prostatic carcinoma.

The current study was undertaken to evaluate the Prostate Specific Antigen (PSA) relapse free survival and the prognostic factors in a total of 38 patients with stages of T2a-b, N0, M0 prostate carcinoma treated with three-dimensional conformal radiotherapy (3D-CRT). Mean 69.63 Gy was given with 3D-CRT, the mean follow up time was 13.89 months, and the mean prebiopsied PSA level was 25.12 ng/ml. The 2-year PSA relapse free survival was 47.37% for the entire group. The 2-year PSA relapse free survival rates were 100% and 44.74% for the patients with Gleason score < or = 7 and greater than 7 (p < or = 0.05). Patients with prebiopsied PSA level < or = 10 ng/ml and the stages of T2a or T2b did not show any significant differences (p > or = 0.05). Although the few case number and short term follow up, in this study 3D-CRT was a new effective technique to prostate cancer for our institutes and the Gleason score was important predictor of PSA relapse free survival.

The effect of tenoxicam on intraperitoneal adhesions and prostaglandin E2 levels in mice.

UNLABELLED: We determined whether tenoxicam administered intraperitoneally in the preoperative period had an effect on the development of postoperative intraabdominal adhesions (IAA). For this purpose, 100 albino mice were divided into four random groups. Mice in Group 1 were given only 1 mL of 0.9% NaCl intraperitoneally, whereas in Group 2, 1 mL of tenoxicam (150 microg = 5 mg/kg) was administered. After the induction of anesthesia, a median laparotomy was performed, and the bowels were traumatized by touching them with powdered gloves before the incision was closed in Groups 3 and 4. Intraperitoneal tenoxicam was administered to mice in Group 4 after skin closure. All mice were killed after 14 days to determine macroscopic and microscopic IAA; prostaglandin E2 levels were also measured. Postoperative evaluation revealed a reduced IAA formation and a parallel decrease in tissue prostaglandin E2 levels in Group 1 and 2 mice. We conclude that intraperitoneal tenoxicam decreased IAA formation with no peritoneal reaction in the postoperative period. IMPLICATIONS: Postoperative intraabdominal adhesions can cause intestinal obstruction, pelvic pain, or infertility. In this study, we showed that intraperitoneally administered tenoxicam decreases tissue prostaglandin E2 levels and intraabdominal adhesions in mice.

Tracheal rupture: a rare complication related to foreign body aspiration.

A one-year-old patient admitted following foreign body aspiration and referred following cardiopulmonary resuscitation in a local hospital was diagnosed to have tracheobronchial rupture. We first assumed puncture of the mucous membrane of the left main bronchus by the tip of the tube. Later, we thought that the rupture might have been caused by rigid bronchoscopy. Etiology and treatment are discussed and recent literature reviewed.

The effect of acute normovolemic hemodilution on homologous blood requirements and total estimated red blood cell volume lost.

BACKGROUND: Acute normovolemic hemodilution combined with retransfusion is one of the various techniques proposed to avoid homologous blood transfusion in cardiac surgery. The purpose of the present paper is to study the effect of the volume of autologous blood collected pre-cardiopulmonary bypass (CPB) on homologous blood requirements and total estimated red blood cell (RBC) volume lost in coronary artery bypass grafting (CABG) surgery. METHODS: Following induction of anesthesia, sequestration of one (5-8 ml/kg; Group I, n = 14) or two units (12-15 ml/kg; Group II, n = 14) of fresh autologous blood was performed under electrocardiographic and hemodynamic control. Group III (n = 14) was designated as the control group. Autologous blood was reinfused at the conclusion of CPB. RESULTS: The use of homologous blood in the study groups was significantly less than in the control group. High-volume phlebotomy did not make a significant difference in the requirement of the homologous blood, while causing a mild increase in the total estimated RBC volume lost. No significant differences could be demonstrated in preoperative, post-CPB and discharge hematocrit levels and postoperative blood drainage between the groups. CONCLUSION: Acute intraoperative hemodilution with high- and low-volume phlebotomy reduced the homologous blood requirements similarly regardless of the amount of phlebotomy.

Prophylactic administration of histamine 1 and/or histamine 2 receptor blockers in the prevention of heparin- and protamine-related haemodynamic effects.

The efficacy of prophylactic administration of H1 and H2 receptor blockers to prevent adverse haemodynamic responses to heparin and protamine was studied. The control group (n = 10) received no histamine receptor blocker, group H1 (n = 10) received oral terfenadine 60 mg, group H2 (n = 10) received oral ranitidine 300 mg, and group H1+H2 (n = 10) received both terfenadine and ranitidine on the night before the operation and on call to the operating room. Heparin sulphate 300 U/kg was injected directly into the right atrium, and protamine hydrochloride was administered at the conclusion of bypass over at least three minutes through a peripheral route. Following the injection of heparin, plasma histamine-like activity (H-LA) was increased significantly in all four groups. While systolic, diastolic, mean arterial and central venous pressures were decreased significantly in the control group, no significant changes were observed in the H1 and H2 groups. Protamine infusion did not lead to an increase in H-LA. Prophylactic administration of histamine receptor blockers (H1 or H2) attenuated the heparin-induced adverse haemodynamic response but did not change the protamine-related haemodynamic effects. Factors other than histamine may play a major role in protamine induced cardiovascular changes.