Comparison of midazolam, propofol and fentanyl combinations for sedation and hemodynamic parameters in cataract extraction.

OBJECTIVE: Midazolam, propofol and fentanyl were compared in terms of sedation during cataract extraction. Hemodynamic parameters, sedation level, postoperative satisfaction, and side effects were investigated. METHODS: The study was carried out in Hacettepe University Hospitals Ophthalmology Operating Theatres in 2005. The patients received only midazolam (0.02 mg kg-1), or midazolam (0.02 mg kg-1) + propofol (0.2 mg kg-1), or midazolam (0.02 mg kg-1) + fentanyl (1 microgram kg-1), or midazolam (0.02 mg kg-1) + propofol (0.2 mg kg-1) + fentanyl (1 microgram kg-1). The sedation level of patients was measured according to a physician questionnaire. Postoperative nausea/vomiting, headache, and patient satisfaction were determined via a patient's evaluation scale. RESULTS: In the groups receiving fentanyl, the hemodynamic response to peribulbar block insertion was minimal (p<0.05) and the sedation level was best (p<0.05). Respiration rate and O2 saturation of patients receiving midazolam, propofol, and fentanyl decreased after sedation (p<0.01) and postoperative satisfaction was high in this group (p<0.01). Patients in the midazolam group showed a prominent reaction to peribulbar block insertion while movement during the operation was obvious (p<0.05). CONCLUSION: The combination of midazolam, propofol, and fentanyl should be preferred to other study groups as the sedation level is suitable for cataract extraction with high postoperative patient satisfaction and without any side effects.

Pediatric obstructive sleep apnea syndrome and anesthetic management.

Sleep-related breathing disorders require special attention in children who spend a considerable time sleeping. Obstructive sleep apnea syndrome is characterized by episodes of upper airway obstruction during sleep. Symptoms include hyperactivity, enuresis, headache, failure to thrive, and increased respiratory effort and total sleep time. The most common cause is adenotonsillar hypertrophy. Coexisting diseases are obesity, neuromuscular and craniofacial anomalies, and Down's syndrome. Early diagnosis is important to minimize neurocognitive, cardiac and developmental complications. Polysomnography is the gold standard for diagnosis. Although the features of pediatric obstructive sleep apnea syndrome are distinctly different from that in adults, it may predispose to the adult type of the syndrome. As therapy concerns several surgical approaches as well as conservative techniques, anesthetic management calls for particular attention. Pre- and postoperative sedation must be performed cautiously and patients must be watched closely with respect to airway obstruction and hypoventilation. Difficult intubation must always be considered.

[Pre-hospital airway management in trauma]. / Travmada olay yerinde havayolu saglanmasi.

Knowledge of trauma is as old as mankind and survived a long way to reach new technologic developments. Being a multisystemic disease, trauma is an important social and financial problem especially in developing countries. Anesthesists possess important roles in the multisystemic management of trauma patients. In our country prehospital life support for trauma victims is primarily realized and arranged by the emergency help and rescue team 112 which belonged to the Ministry of Health. Several courses are arranged for the team especially about endotracheal intubation and resuscitation in the field. Acute major airway injuries require an early diagnosis and a prompt treatment to improve their outcomes. Typical injuries causing alterations in oxygenation or ventilation are head, spinal cord and thoracic traumas. The use of cuffed tracheal tube remains the definitive 'gold standard' for airway control. Tracheal tube placement requires experience and high degree of skill. The laryngeal mask airway, intubating laryngeal mask airway and oesophageal-tracheal combitube are also indicated in maintaining control of airway during emergency trauma patients in the field. A probable occurrence of cervical spine fracture must be assumed while maintaining airway patency. On-site airway aspiration, and monitoring of carbon dioxide must be realized in trauma victims.

[Tracheal rupture during esophagectomy]. / Ozofajektomi sirasinda gelisen trakea rüptürü.

Traumatic and iatrogenic injuries of the trachea are rare. The most common causes are motor vehicle, especially motorbike accidents. The incidence of tracheal rupture during esophagectomy is reported as 4-10 %. This complication may occur during the dissection of the upper segment of the esophagus from the posterior membranous trachea, especially when there are adhesions. We reported a tracheal rupture during esophagectomy in a 29 year old man with cancer at the post cricoid region of the trachea, which had been irradiated for three months before the operation. While the esophagus was being dissected from the trachea, a vertical rupture extending to carina occurred on the posterior wall causing severe hypoventilation. To improve ventilation the cuffed armored tubes were inserted into both main bronchi which were connected to a "Y" piece. Based on this case we discussed casualties, risk factors, symptoms and anesthetic management of tracheal rupture.

Infusion and bolus administration of cisatracurium--effects on histamine release.

The purpose of this study is to evaluate the usefulness of Cisatracurium Besilat (CB), and the method of its administration during laparotomies on adult patients, to determine whether CB caused cutaneous, systemic or chemical evidence of histamine release. This study was conducted as a randomized, double-blind clinical trial on 38 patients (ASA I-II). After a standard anesthetic induction with fentanyl and propofol, patients received an i.v. bolus CB (0.15 mg/kg in Group A (n=20) or Group B (n=18). In Group B, 0.18 mg/kg/h infusion was started. Following reaching stable muscle relaxations for intraabdominal operation and for recovery, Group A (Bolus group) and Group B (Infusion group) were compared. Train-of-four fade during recovery of block were recorded after administration of CB. The heart rate and arterial blood pressure were monitored noninvasively. There were no significant hemodynamic differences among the groups. 25%-75% spontaneous recoveries were (mean+/-s) 12.75+/-4.52, 16.11+/-9.20 minutes for Group A, Group B. 70% TOF Ratios were (mean+/-s) 1.07+/-0.13, 1.39+/-0.38 hours for the same groups. There was no consistent correlation between hemodynamic changes, cutaneous manifestations and histamine concentrations. We conclude that CB does not cause systemic or cutaneous histamine release. The infusion method of cisatracurium has a stable level of curarization without side effect and there were no significant recovery time differences between the groups.

The effect of premedication on preoperative anxiety.

The aim of this study was to evaluate the effect of premedication on anxiety, cortisol, residual gastric volume and gastric pH. Following the approval of the institutional Clinical Research Ethics Committee, 100 patients in ASA I-II scheduled for elective gynecologic surgery, were included into a double blind study. Patients were randomly allocated into two groups; the placebo and the premedicated. Oral 10 mg diazepam in the evening before surgery and 1.5 mg midazolam at least 15 min before surgery. The same anesthetic procedure was applied for both groups. Anxiety levels of patients were assessed by using Spielberger State-Trait Anxiety Inventory Scale (STAIs). Blood samples for cortisol measurements were obtained at the preoperative visits, preanesthesia and intraoperative phases. Gastric contents were collected through an orally inserted gastric tube, acidity was measured by using Merck's pH paper. In placebo group, the preanesthetic STAIs values were increased compared to the values obtained at preoperative visit (p < 0.001). The preanesthetic STAIs values were decreased in premedicated group (p < 0.001). The changes of preanesthetic and preoperative visit values were statistically different (p < 0.001). The preanesthetic and intraoperative cortisol values were increased in both groups compared to values of preoperative visit. The augmentation was significantly higher in the placebo group (p < 0.05). Positive correlation was observed between basal state anxiety and basal cortisol values and preanesthetic STAIs and cortisol values in the placebo group (r = 0.325, p < 0.05). These data support that preoperative sedation suppresses the preoperative anxiety and the cortisol augmentation resulting from surgery and stress.

[Anaesthesia in electroconvulsive therapy]. / Elektrokonvülsif Tedavide Anestezi Yaklasimi.

Electroconvulsive therapy (ECT) is a safe and efficient procedure performed for the treatment of drug resistant depression and other psychiatric disorders. Nowadays, its administration under general anaesthesia is a worldwide process. Anaesthetic management generally involves a short acting barbiturate such as thiopental in induction followed by a muscle relaxant. Succinylcholine is the drug of choice for muscle relaxation. This approach prevents patients from suffering hazardous orthopaedic injuries due to confusion. The effectiveness of ECT depends on an adequate seizure, and so the anaesthetist should be aware of the factors that influence the duration of seizures as well as concomitant diseases and potential adverse antidepressive drug reactions. An acute haemodynamic response due to sympathetic discharge in the course of the seizure provokes abrupt cardiovascular and cerebrovascular changes such as bradycardia, tachycardia, hypertension and raised intracranial pressure. The control of responses by b-blockers and similar agents is especially important in patients with cardiac or intracerebral problems. ECT is applicable in nearly all age groups and even in pregnant subjects. The aim of this article is to review the aspects of anaesthetic management of safe and effective ECT.

Minimum effective dose of dexamethasone after tonsillectomy.

BACKGROUND: The minimum effective dose of dexamethasone in conjunction with 50 microg x kg(-1) ondansetron was evaluated in the treatment for vomiting after elective tonsillectomy or adenotonsillectomy. METHODS: A total of 102 healthy children between 2 and 12 years of age participated in this prospective, randomized, double-blind study. A single intravenous (i.v.) dose of dexamethasone (50, 100, 150 microg x kg(-1), maximum dose 8 mg) with ondansetron (50 microg x kg(-1)) was administered just before the end of surgery. Equal volumes of normal saline were given to the control group. General anaesthesia was induced and maintained by inhalation of N2O/O2 and sevoflurane. All other preoperative and postoperative medications (including a supplementary dose of antiemetics if necessary), anaesthesia and surgical techniques were standardized. RESULTS: No significant differences were observed between groups in postoperative vomiting on the day of surgery and the next day, or in the need for postoperative pain medication and supplementary doses of antiemetics (P > 0.05). CONCLUSIONS: These results indicate that surgical technique and anaesthetic management used in this study could be the cause of the lower incidence of nausea and vomiting. Assessment of nausea and vomiting in a prospective study with larger groups of patients may reflect different results.

Effects of low and high intra-abdominal pressure on immune response in laparoscopic cholecystectomy.

OBJECTIVE: Immunosuppression is directly related to the degree of trauma. The aim of this study is to compare the effects of low and high intra-abdominal pressure on immune response in moderate surgical trauma. METHODS: Twenty-two patients, scheduled for laparoscopic cholecystectomy, were randomly allocated to one of 2 groups according to intra-abdominal pressure: low and high intra-abdominal pressure. This study was conducted in the Hacettepe University Faculty of Medicine, Operation Room, Ankara, Turkey. Serum interleukin (IL)-2 and IL-6 levels were measured. RESULTS: Serum IL-2 showed a significant decrease before the incision in high intra-abdominal pressure group. The increase in serum IL-6 at the end of surgery and postoperatively was lower in low intra-abdominal pressure group. CONCLUSION: These results, can be interpreted as the immune system, are less depressed when there is lower intra-abdominal pressure. This may have clinical implications in immunocompromised patients.

Byler's disease and anesthetic consideration.

Byler's disease is an autosomal recessive condition characterized by intrahepatic cholestasis, progressive fibrotic changes and finally cirrhosis that leads to death during childhood. This is a report of a six-year-old girl with Byler's disease and retrobulbar hematoma as a result of trauma who underwent enucleation and implantation. This case report describes the anesthetic features of a patient with Byler's disease in which anesthetic agents with no or minimal hepatotoxic effect should be used to avoid deterioration of liver function.