Effects of Osteotomy on Hemodynamic Parameters and Depth of Anesthesia in Rhinoplasty Operations.

BACKGROUND: Bleeding during rhinoplasty leads to many undesirable effects, such as loss of vision in the surgery area, complications during the procedure, and postoperative complications. The most important effect that increases bleeding is hemodynamic changes during surgery. Considering that osteotomy is the most challenging process in rhinoplasty, this study aimed to examine the hemodynamic changes during osteotomy and changes in the depth of anesthesia. METHODS: A total of 50 patients, aged 18 to 65 years with an ASA (American Society of Anesthesiology) score of 1 and 2, who underwent osteotomy during rhinoplasty under general anesthesia, were examined retrospectively. After routine monitoring, the patients underwent general anesthesia induction and endotracheal intubation. Before the surgery, they received remifentanil 1 µg/kg as an intravenous bolus followed by 0.5 µg/(kg·min) as intravenous infusion until the end of the surgery. The hemodynamic parameters and depth of anesthesia [bispectral index (BIS) values] of the patients were examined before anesthesia, 10 minutes before osteotomy, during osteotomy, and 10 minutes after osteotomy. RESULTS: A significant difference was found in heart rate (beats/min), systolic and diastolic blood pressures (mm Hg), and BIS values of the patients measured before, during, and after osteotomy (P < 0.001). The heart rate, systolic and diastolic blood pressures, and BIS values were significantly higher during osteotomy. Until the 10th minute after osteotomy, all 4 parameters nearly reached the values measured before osteotomy. CONCLUSIONS: Osteotomy directly affects hemodynamic parameters and depth of anesthesia. Hence, it is of utmost importance that the analgesic need and depth of anesthesia are adequately monitored and adjusted during osteotomy. By suppressing hemodynamic stress responses, the amount of bleeding can be reduced, thus increasing the surgical success and the patient's comfort.

The Effect of Erector Spinae Plane Block on Laparoscopic Cholecystectomy Anesthesia: Analysis of Opioid Consumption, Sevoflurane Consumption, and Cost.

Background: Erector spinae plane (ESP) block has been increasingly suggested for laparoscopic cholecystectomy (LC) as a part of multimodal analgesia in many studies. However, there is not any study that investigated the perioperative effects of ESP block on anesthetic agent consumption and cost of LC anesthesia. This is the first study that evaluates the effect of ESP block in terms of cost-effectiveness, intraoperative consumption of inhalation agents, and perioperative consumption of opioids. Materials and Methods: In this prospective observational study, 81 patients who underwent LC were included. Patients were divided into two groups: In Group ESP (n = 39) bilateral ultrasound-guided ESP block was performed in preoperative period and in Group non-ESP (n = 42) ESP block was not performed. After standard general anesthesia protocol, anesthesia was maintained with 2% sevoflurane in 50% air and 50% oxygen with controlled ventilation in both groups. All patients were monitored with electrocardiography, noninvasive blood pressure, pulse oximetry, end-tidal carbon dioxide, and bispectral index. The consumption of sevoflurane and opioids in the intraoperative and postoperative 24 hours was recorded. The costs of drugs were determined by multiplying total consumed amounts with unit prices. Results: The costs and the consumed amounts of remifentanyl, sevoflurane, and tramadol were significantly higher in non-ESP group in the perioperative period (respectively, P < .001, P = .01, and P < .001). Conclusions: ESP block for LC decreased the consumed amount and cost of inhaled agents and opioids in the perioperative period.

Effectiveness of Intraoperative Laser Acupuncture Combined with Antiemetic Drugs for Prevention of Postoperative Nausea and Vomiting.

Introduction: Postoperative nausea and vomiting (PONV) are frequent in patients undergoing laparoscopic cholecystectomy. The aim of this study is to evaluate the effectiveness of intraoperative laser acupuncture stimulation of Pericardium 6 (PC6) and Large Intestine 4 (LI4) acupoints combined with antiemetic drug prophylaxis on PONV. Methods: A total of 88 patients, scheduled for laparoscopic cholecystectomy, were assigned into 2 groups. Group I received bilateral laser acupuncture on PC6 and LI4 acupoints after induction of anesthesia and also received antiemetic drug (metoclopramide) prophylaxis. Patients in Group II received only antiemetic drug prophylaxis. Nausea and vomiting frequencies and need for rescue antiemetic drug (ondansetron) were recorded after extubation, at 30th minute at recovery room and at 6th hour at ward. Results: The incidence of nausea and rescue antiemetic drug need was higher at postoperative 6th hour in Group II. Vomiting was not different in groups at any time. Conclusion: Intraoperative laser acupuncture stimulation of PC6 and LI4 acupoints combined with antiemetic drug prophylaxis decreases nausea and rescue antiemetic drug need in late postoperative period in patients undergoing laparoscopic cholecystectomy.

Red Cell Distribution Width in Diagnosis of Brain Death.

INTRODUCTION: Red blood cell distribution (RDW) is a hematologic index automatically calculated by blood cell counters. Research about RDW in traumatic brain injury showed positive correlation between high RDW values and mortality, which inspired us to investigate whether RDW could be used as a supportive diagnostic biomarker for diagnosis of brain death. Our hypothesis is that RDW may be useful as a biomarker that supports the diagnosis of brain death. METHODS: After approval of the ethics committee, 209 patients who had been diagnosed with brain death between January 2012 and July 2018 were retrospectively reviewed. The RDW values of patients on the days of admission, brain death, and cardiac arrest were recorded. Data were collected from hospital database and patient charts. RESULTS: Statistical analysis revealed that the RDW values on the days of brain death and cardiac arrest were significantly higher than on the day of admission. In addition, the RDW values for the cardiac arrest day were significantly higher than on the day of brain death (P < .001). CONCLUSIONS: We can say that the increase in RDW, which is reported to be an indicator of mortality for many diseases, can be a supporting biomarker for brain death diagnosis when evaluated concomitantly with clinical diagnostic criteria.

[An assessment of physicians attitudes toward opioid usage and opiophobia: Results of a survey from a training and research hospital]. / Doktorlarin opioid kullanimi ve opiofobiye yaklasimlarinin degerlendirilmesi: Bir egitim ve arastirma hastanesinden anket sonuçlari.

OBJECTIVES: When researches examined, cancer pain and other cronic pain, serious mismanagement and undermedication in treating chronic pain especially using opioids continuing problem. This study was designed to examine the barriers to adequate opioid usage, especially as they could be associated with experience and medical discipline. METHODS: The survey conducted among phycians working in Ankara Numune education and research hospital on July of 2015. A 29 item survey was used to measure physicians attitudes and knowledge about using opioids. RESULTS: We have included 156 doctors in our study.We found that %82.7 of doctors have not been educated in the pain subject.%48.8 of doctors see themselves capable of prescribing opioid medication and %67.9 of doctors are feeling uneasy when prescribing opioids also a lot of doctors are not willing to give prescriptions of opioids.When analyzing our data we have found that opioids related prejudices are not related with title or experience.It is interesting that the doctors who were anxious when prescribing opioids to their patients they want for themselves when in need opioid precriptions and again when in need they want increasing doses of opioid. CONCLUSION: Resembling the studies in the literature in our study, we've found that doctors have poor knowledge about opioids and opiophobia it's frequent among the doctors.Poor knowledge of opioids and overcoming the opiophobia and medicating with opioids when medical status of patients emposes made us think that in service training should be started immeadiately.

Unexplained neuropsychiatric symptoms in intensive care: A Fahr Syndrome case.

Fahr Syndrome is a rare disease where calcium and other minerals are stored bilaterally and symmetrically in the basal ganglia, cerebellar dentate nucleus and white matter. Fahr Syndrome is associated with various metabolic disorders, mainly parathyroid disorders. The presented case discusses a 64-year old male patient admitted to the intensive care unit of our hospital diagnosed with aspiration pneumonia and urosepsis. The cranial tomography examination to explain his nonspecific neurological symptoms showed bilateral calcifications in the temporal, parietal, frontal, occipital lobes, basal ganglia, cerebellar hemisphere and medulla oblongata posteriorly. His biochemical test results also indicated parathormone-calcium metabolic abnormalities. Fahr Syndrome must be considered for a definitive diagnosis in patients with nonspecific neuropsychiatric symptoms and accompanying calcium metabolism disorders in order to control serious morbidity and complications because of neurological damage.

Necrotizing fasciitis due to Streptococcus mitis caused by accidental human bite.

Human bite wounds are more prone to infection than animal bites, which may cause necrotizing soft tissue infections such as myositis, fasciitis. Both aerobic and anaerobic microorganisms may be responsible, including Streptococcus spp., Staphylococcus aureus, Peptostreptococcus spp. Necrotizing fasciitis is characterized by serious tissue destruction and systemic toxicity with high morbidity and mortality. We report a patient with Streptococcus mitis associated necrotizing fasciitis on the upper extremity resulting from an accidental human bite, which caused nearly fatal infection. Prophylactic antibiotic treatment should be given after a human bite to prevent infection. If the infection signs and symptoms develop, rapid diagnosis, appropriate antibiotic and surgical therapy should be administered immediately. Streptococcus mitis is a viridans streptococcus, usually known as a relatively benign oral streptococcus. To our knowledge, this is the first necrotizing fasciitis case due to Streptococcus mitis after human bite.

Endotracheal Tube Obstruction: A Manufacturing Defect.

Various manufacturing defects of endotracheal tubes are encountered in anaesthesia practice. One of the important defects of an endotracheal tube is that a partial or complete obstruction can be potentially life-threatening. Manufacturing defects may not be ascertainable by routine inspection. In this case report, we report a partial airway obstruction caused by a plastic membrane in the connector of an endotracheal tube as a manufacturing defect.

Phenytoin induced toxic epidermal necrolysis.

Toxic Epidermal Necrolysis (TEN) which is characterized by the detachment of the epidermis from the dermis is a rare (1.89/1.000.000 annually) and potentially life-threatening condition. The overall mortality is 20 - 30%. TEN is characterized by sudden apoptosis of keratinocytes leading to mucous membrane erosions and epidermal detachment; detachment of less than 10% of the total body surface area defines Stevens-Johnson Syndrome (SJS); when greater than 30%, it defines TEN, while intermediate cases are called SJS/TEN overlap. Many drugs, including prednisolone, cyclosporin, and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of phenytoin as a prophylactic anticonvulsant after brain surgery, particularly for brain tumors, is a common practice, regardless of whether the patient has a previous history of convulsions. This report described a case of haemorrhagic stroke where phenytoin use induced TEN.

Wernicke's Encephalopathy After Longterm Feeding with Parenteral Nutrition.

Wernicke's encephalopathy occurs due to thiamine (vitamin B1) deficiency which is characterized by occulomotor dysfunction, confusion and ataxia. Although it is most common with alcoholism, can also be seen due to hyperemesis caused by chemotherapy, Crohn's disease, gastrointestinal system surgery, AIDS, bariatric surgery and longterm feeding with parenteral nutrition. In this case, a 51-year-old woman who was treated with longterm total parenteral nutrition due to hyperemesis and had the diagnosis of Wernicke's encephalopathy after admission to the intensive care unit is presented.

Can ephedrine pretreatment be effective in alleviating rocuronium injection pain?

OBJECTIVE: The aim of this randomized, double-blind, placebo-controlled study was to evaluate the effect of ephedrine pretreatment on the intensity of rocuronium injection pain when rocuronium was applied by timing principle and also to compare this effect with lidocaine and placebo. SUBJECTS AND METHODS: 120 American Society of Anesthesiology risk score I-II patients scheduled for elective surgery under general anesthesia were randomized into three groups to receive either 70 µg/kg ephedrine (ephedrine group, n = 40) or 0.5 mg/kg lidocaine (lidocaine group, n = 40) or 5 ml NaCl 0.9% (placebo group, n = 40) as pretreatment. Thirty seconds after pretreatment drugs, rocuronium 0.6 mg/kg was administered by the timing principle and rocuronium injection pain scores were recorded. Twenty seconds after rocuronium administration, anesthesia was induced with thiopental and the patient's trachea was intubated. Hemodynamic parameters and adverse effects were recorded. RESULTS: The overall frequency of having pain was 82.5, 52.5 and 22.5% in placebo, ephedrine and lidocaine groups, respectively. Although the frequency of mild and moderate pain scores was higher in the ephedrine group than in the lidocaine group, this difference was not statistically significant (p = 0.032 and p = 0.001, respectively). CONCLUSION: Although not as effective as lidocaine 0.5 mg/kg, 70 µg/kg ephedrine pretreatment was able to alleviate rocuronium injection pain when rocuronium was applied by timing principle.

Low dose levobupivacaine 0.5% with fentanyl in spinal anaesthesia for transurethral resection of prostate surgery.

BACKGROUND: Levobupivacaine 0.5% and bupivacaine 0.5% were shown to be equally effective in spinal anaesthesia. In previous studies, low dose bupivacaine with an intrathecal opioid was used successfully in urological surgery. The aim of this study was to evaluate the clinical effectiveness and block quality of low dose levobupivacaine, and compare it with low dose bupivacaine when they are combined with fentanyl in transurethral resection of prostate surgery. METHODS: Forty nine patients undergoing transurethral prostate surgery were enrolled in this prospective, randomized and double blind study. Patients in levobupivacaine group received 5 mg levobupivacaine + 25 µg fentanyl and bupivacaine group received 5 mg bupivacaine + 25 µg fentanyl. Demographic data, surgery times, hemodynamic parameters, block qualities and patient and surgeon satisfactions were recorded. RESULTS: Demographic data, surgery times and patient and surgeon satisfactions were similar in both groups. Hemodynamic parameters were comparable and stable during the procedure in both groups. Sensory block characteristics were comparable and clinically effective in both groups. While 3 patients in bupivacaine group had Bromage score of 3 at the beginning of the surgery, no patient in levobupivacaine group had this score and this difference was significant (p = 0.042). Bromage scores at the end of the surgery were comparable in both groups. CONCLUSIONS: In conclusion, for transurethral prostate surgery 5 mg levobupivacaine with 25 µg fentanyl can provide stable hemodynamic profile, patient and surgeon satisfaction and effective sensorial blockade with less motor blockade in spinal anaesthesia; so it could be used at low doses as a good alternative to bupivacaine.

Thoracic paravertebral block performance for modified radical mastectomy with axillary dissection in a patient with severe chronic obstructive pulmonary disease.

We present the case of an 86-year-old patient with severe chronic obstructive pulmonary disease undergoing modified radical mastectomy with axillary dissection by thoracic paravertebral block (PVB). Use of thoracic PVB provided hemodynamic and respiratory stability, excellent unilateral anesthesia and high patient satisfaction.

"Anesthesia mumps" after electroconvulsive therapy anesthesia.

Acute transient swelling of the parotid gland in association with anesthesia is known as "anesthesia mumps." We report an acute bilateral parotid swelling in a patient after electroconvulsive therapy anesthesia.

Comparison of paravertebral block versus fast-track general anesthesia via laryngeal mask airway in outpatient inguinal herniorrhaphy.

PURPOSE: Outpatient inguinal herniorrhaphy (IH) can be successfully performed under general, regional, or local anesthesia. In this study recovery profile, postoperative pain scores, incidence of adverse effects, and patient and surgeon satisfaction were compared between paravertebral block (PVB) and fast-track general anesthesia (GA) via laryngeal mask airway (LMA) for outpatient IH. METHODS: Sixty patients were randomly assigned to receive either PVB or GA under standardized protocols (group PVB: at T9-L1 levels, 5 mL of 0.5% levobupivacaine for both procedures, and continuous propofol sedation; group GA: GA with 2 mg kg⁻¹ propofol induction and 2-4% desflurane maintenance via LMA, and routine antiemetic prophylaxis and multimodal analgesic treatment). Anesthesia-related, onset, recovery, and home discharge times, hemodynamic changes, pain, and incidence of adverse effects were compared. RESULTS: Anesthesia-related time and onset time were longer, but recovery and home discharge times were shorter in group PVB. Verbal rating scores (VRS) at 30, 60, 120, and 180 min and 6, and 12 h post-surgery were significantly lower in group PVB patients. VRS at 18, 24, and 48 h were comparable in both groups. No patient in group PVB and eight patients in group GA needed meperidine in the post-anesthesia care unit, and time to first analgesic and first rescue analgesic requirements were significantly longer in group PVB. CONCLUSION: In outpatient IH, PVB with 0.5% levobupivacaine provided improved recovery, long-lasting analgesia, shorter recovery room stays, and earlier home readiness time than fast-track GA via LMA.