Effects of remifentanil and propofol on distant organ lung injury in an ischemia-reperfusion model.

Our aim was to evaluate lung injury due to oxidative stress and antioxidant activity levels in an infrarenal ischemia-reperfusion model and to compare prevention effects of single and combined use of propofol and remifentanil. In this study, a total of 40 adult Wistar Albino rats were randomly divided into five groups of eight rats as SHAM, physiological saline, intraperitoneal propofol, remifentanil, and propofol and remifentanil groups. Blood and tissue samples were obtained after 80 min of reperfusion. The malondialdehyde (MDA) level, a measure of lipid peroxidation, was measured in lung tissue samples and red blood cells; additionally, total oxidant status and total antioxidant capacity of lung tissues were measured and histopathological examination was performed. Distant organ (lung) injury developed due to lower extremity ischemia-reperfusion was created by infrarenal aortic clamping. The lipid peroxidation product MDA and total oxidant levels were increased, but there was insufficient antioxidant protection both in the lung tissues and red blood cells. While propofol prevented this injury consistent with its proposed antioxidant properties; no protective effect of remifentanil was observed. On the contrary, it showed oxidative stress increasing effect. This study concluded that the antioxidant effect of propofol was suppressed by remifentanil in the case of combined use.

Factors associated with preoperative anxiety levels of Turkish surgical patients: from a single center in Ankara.

BACKGROUND: Preoperative anxiety and stress are undoubtedly a difficult experience in patients undergoing elective surgery. These unpleasant sensations depend on several factors. The objective of this study was to evaluate the preoperative anxiety levels in a sample of Turkish population, as well as the underlying causes using the Spielberger State-Trait Anxiety Inventory (STAI anxiety) scale. METHODS: The study was conducted according to the Declaration of Helsinki and was approved by the local ethical committee. All participants gave written informed consent upon having received detailed information on the study. Upon entry in the study, state and trait anxiety questionnaires were completed by 186 patients scheduled for elective surgery. The influencing factors in regard to age, sex, educational status and others were also reported. RESULTS: There was a statistically significant positive correlation between state and trait anxiety scores in this Turkish population. While the most important predictive factors that affected state-STAI scores were age, sex and duration of sleep the night before surgery; educational status and age were the best predictors for determining the variation in trait-STAI scores. CONCLUSION: The factors affecting anxiety levels in different populations might vary among different countries. Interestingly, in this sample of Turkish population, the trait anxiety levels were found to be higher from state-anxiety levels, especially in women and less educated people. Thus, doubts about operation and anesthesia are overlooked. This could be attributed to the low to intermediate life standards of people admitted to our hospital.

Our Anaesthetic Experiences in Patients Undergoing Percutaneous Mitraclip Implantation.

OBJECTIVE: Percutaneous mitraclip implantation system, is a new technique developed for patients with high surgical risks. It is generally performed in a catheterisation laboratory with the guidance of fluoroscopy and transesophageal echocardiography. In this study, we aimed to share our experiences on anaesthetic in patients undergoing mitraclip implantation under general anaesthesia. METHODS: Eighty four patients with severe, symptomatic mitral insufficiency, who had undergone MitraClip implantation under general anaesthesia between July 2012 and March 2015 (54 male, 30 female; mean age: 68.5±10.2 years) were retrospectively investigated in terms of anaesthetic management. RESULTS: Of the 84 patients undergoing percutaneous mitraclip implantation under general anaesthesia, 84.5% had sodium thiopental and 75% had midazolam for anaesthesia induction. For the maintenance of anaesthesia, 57% of the patients were reported to have sevoflurane, whereas the rest had desflurane. The mean duration of the procedure and anaesthesia was 140.9±48.2 mins and 165.7±50.6 min, respectively. Seventy seven patients were transported to the intensive care unit and intubated after the procedure. The median extubation time was 3 h. Length of stay in the intensive care unit was 2 days, whereas it was 4 days for hospital stay. One patient died during the procedure and six patients died after the procedure. CONCLUSION: Percutaneous mitraclip implantation procedure is quite difficult for anaesthesiologists because of the procedure itself and the population on which the procedure is performed. The primary aim of anaesthesia management is to provide haemodynamic stability. The preoperative preparation and anaesthesia methods should be the same as for patients undergoing cardiac surgery. It is reported that as the experience regarding this subject increases, success of the procedure increases, with better protected haemodynamic stability, less inotropic and vasopressor requirement and shorter length of hospital stay.

Impact of different anesthetic managements in outcomes of transcatheteraortic valve implantation: the first Turkish experience.

BACKGROUND/AIM: Transcatheter aortic valve implantation (TAVI) has emerged as a new therapy in aortic stenosis patients with high operative risk. Advances in experiences have shifted the choice of anesthesia from general to local anesthesia and sedation for these patients. We compared our anesthetic experiences in our institute in a period of 2.5 years. MATERIALS AND METHODS: A total of 151 (86 females, 65 males, mean age 76 years) symptomatic aortic stenosis patients undergoing transfemoral TAVI under general anesthesia (GA) (n = 79) and local anesthesia and sedation (LAS) (n = 72) were evaluated retrospectively in regards to anesthetic issues. RESULTS: The mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) values of patients in the GA and LAS groups were 17 and 12, respectively. The anesthesia duration was significantly shorter in the LAS group (P < 0.001) and 16.7% of the patients in the LAS group were switched to general anesthesia. Length of stay in the intensive care unit was similar in the two groups. CONCLUSION: TAVI, applied in high-risk populations, has many challenges for anesthesiologists. With technological advances, it is possible to perform these procedures under sedation with variable advantages. Thus, future studies in regard to anesthesia are required for the success of the procedure and patient safety.

Sedation Monitoring and Management during Percutaneous Endoscopic Lumbar Discectomy.

Percutaneous endoscopic laser discectomy (PELD) is a painful intervention that requires deep sedation and analgesia. However, sedation should be light at some point because cooperation by the patient during the procedure is required for successful surgical treatment. Light sedation poses a problem for endotracheal intubation, while patients placed in the prone position during percutaneous endoscopic discectomy pose a problem for airway management. Therefore, under these conditions, sedation should be not deeper than required. Here we report the sedation management of three cases that underwent PELD, with a focus on deep and safe sedation that was monitored using bispectral index score and observer's assessment of alertness/sedation score.

The Effects of Different Anaesthetic Techniques on Surgical Stress Response During Inguinal Hernia Operations.

OBJECTIVE: The aim of this study is to compare the effects of 3 different kinds of anaesthesia on stress response induced by surgery. METHODS: Sixty patients aged between 25-70 American Society of Anesthesiologists (ASA) I-II group to undergo inguinal herniography were included in this study. Patients were randomly divided into 3 groups of 20. Group 1 received general anaesthesia with sevoflurane/air/remifentanil, patients in Group 2 received total intravenous anaesthesia (TIVA) with propofol/air/remifentanil and Group 3 received spinal anaesthesia induced by hyperbaric bupivacaine, adjoined by remifentanil sedation. Mean arterial pressure (MAP), heart rate and SpO2 values were recorded preoperatively, intraoperatively and postoperatively at certain periods. Cortisol, leptin and glucose levels were preoperatively detected. Intervals were as; 15 minutes prior to the induction of anaesthesia, at intraoperative first hour and at the postoperative third and twenty-forth hours. RESULTS: MAP and heart rate values were similar in the inhalational anaesthesia and TIVA groups but relatively higher in the spinal anaesthesia group. Blood glucose levels were elevated, insulin levels were decreased in all groups, at the intraoperative first hour. Biphasic variation in blood leptin levels was observed in all groups, as the levels were lower than the preoperative control values at the intraoperative first and postoperative third hours and significantly higher at the postoperative twenty-forth hour. There was a significant decrease in cortisol level percentage change in the TIVA group at the intraoperative 1st hour, increasing in the other groups. CONCLUSION: We concluded that TIVA supresses the stress response induced by surgery better by lowering cortisol levels, leading to a lower increase in blood glucose levels and a lower decrease in blood insulin levels when compared to others. Furthermore, leptin levels were increased at the postoperative twenty-forth hour. The lower increase at the postoperative twenty-forth hour in the TIVA group can be correlated with the anaesthetic agent.

Anesthetic management and perioperative complications in transcatheter aortic valve implantation: the Turkish experience.

BACKGROUND/AIM: To describe the anesthetic management and early results of transcatheter aortic valve implantation (TAVI) in a single center in Turkey. MATERIALS AND METHODS: We evaluated 79 (54 females, 25 males; mean age: 76 ± 9 years) consecutive symptomatic patients with severe aortic stenosis who underwent TAVI under general anesthesia between July 2011 and September 2012. We preferred a transfemoral approach as the first option. RESULTS: The duration of anesthesia was 149 ± 49 min. Thirty-eight percent of the patients were extubated in the cardiac catheterization laboratory. Three patients required a permanent pacemaker, while 8 patients required inotropic support in the postoperative period. Mortality rate was 9% within 30 days. Fifteen patients had vascular complications, of which 53% were treated surgically. CONCLUSION: Today, as a result of developments in technology, TAVI can be considered as a beneficial alternative treatment option for inoperable aortic stenosis patients. Thus, anesthesiologists will be confronted with a number of TAVI cases, and so they should be prepared to face issues related to the patient's safety both during the administration of anesthesia and in the postoperative period in the near future.

The impact of OGG1, MTH1 and MnSOD gene polymorphisms on 8-hydroxy-2'-deoxyguanosine and cellular superoxide dismutase activity in myocardial ischemia-reperfusion.

Ischemia-reperfusion (I/R) injury, by inducing oxidative DNA damage, is one of the leading causes of increased patient morbidity and mortality in coronary artery by-pass grafting (CABG) surgery. 8-Hydroxyguanine (8-OHG) is an important oxidative base lesion. The 8-oxoguanine glycosylase (hOGG1) and hMTH1, which have several polymorphisms, remove 8-OHdG from the nucleotide pool. We investigated whether there are any correlations the biomarkers of oxidative stress (superoxide dismutase; SOD and 8-OHdG in serum) with genotype for two DNA repair genes (OGG1 and MTH1) and an antioxidant enzyme gene (manganese superoxide dismutase; MnSOD). Therefore, we measured DNA damage (8-hydroxy-2-deoxyguanosine; 8-OHdG) and endogenous antioxidant activity (SOD) at five different time points (T1, before anesthesia; T2, after anesthesia; T3, after ischemia; T4, after reperfusion and T5, after surgery). and also, MnSOD and MutT homolog 1 (MTH1) genes polymorphisms were genotyped by polymerase chain reaction-restricted fragment length polymorphism (PCR-RFLP) in patients undergoing coronary artery by-pass grafting (CABG) surgery. No statistically significant differences were detected in the levels of 8-OHdG and SOD in serum in terms of OGG1 Ser326Cys, MTH1 Val83Met and MnSOD Ala16Val genetic polymorphisms. Our results suggest that OGG1, MTH1 and MnSOD gene polymorphisms are not genetic risk factors for I/R injury.

Comparison of efficacy of dexketoprofen versus paracetamol on postoperative pain and morphine consumption in laminectomy patients.

OBJECTIVES: The aim of this prospective randomized, double-blind study was to evaluate the analgesic efficacy and opioid-sparing effects of preemptive single dose of dexketoprofen trometamol in comparison with that of paracetamol or placebo for elective lumbar disc surgery, over a 24-hour (h) investigation period. METHODS: After institutional approval and informed consent had been obtained, 75 patients scheduled for single level lumbar disc surgery were randomly allocated into three equal groups. Patients received oral dexketoprofen 25 mg (Group D), 500 mg paracetamol (Group P) or placebo tablets (Group C) 30 minutes (min) before induction of standard anesthesia. Patient-controlled analgesia was supplied postoperatively using morphine. Hemodynamics, visual analogue scale (VAS), sedation score, morphine consumption, and side effects were recorded every 15 min in the first hour and at 2, 6 and 24 h after surgery. RESULTS: The mean pain scores were similar among groups (p>0.05). The cumulative (SD) 24-h morphine consumption was 28.1 mg, 40.6 mg, and 43.6 mg for Groups D, P and C, respectively. The amount of morphine use at 2, 6 and 24 h was significantly lower in Group D (p<0.006). Hemodynamic parameters, sedation scores and side effects did not differ among the groups (p>0.05). CONCLUSION: The study demonstrated that preemptive dexketoprofen trometamol 25 mg is associated with a decrease of up to 35% in morphine consumption compared with placebo over the first 24 h following lumbar disc surgery; however, paracetamol 500 mg did not show the expected opioid-sparing effect comparatively.

Comet assay in evaluating DNA damage associated with ischaemia-reperfusion injury in patients undergoing coronary surgery.

Ischaemia-reperfusion (I/R) injury is responsible for a number of conditions such as coronary bypass and myocardial infarction, and deaths. Oxygen-free radicals formed during I/R have been proposed as the leading causes of tissue injury, and they play an important role in I/R injury. I/R induces oxidative DNA damage (such as purinic and pyrimidinic base lesions). Comet assay is a suitable and sensitive method for early detection of low-level DNA damage. We used modified alkaline comet assay in peripheral blood lymphocytes and evaluated I/R-induced DNA damage in patients undergoing coronary artery bypass graft (CABG) operation (in vivo model for I/R). No statistically significant difference in DNA damage levels was found before surgery, after anaesthesia, ischemia, reperfusion, and surgery. However, blood lactate levels (assessed in parallel with the comet assay) increased after I/R and did not return to the baseline level. Our findings showed that I/R injury did not induce DNA damage, but increased the lactate levels. This finding suggests that there might be reversible and uncommon necrosis that did not reflect on overall DNA base damage. Further studies are needed using this approach.

[Comparison of the effects of lidocaine, lidocaine plus tramadol and lidocaine plus morphine for intravenous regional anesthesia]. / Intravenöz rejyonal anestezide kullanilan lidokain, lidokain-tramadol ve lidokain-morfinin etkinliklerinin karsilastirilmasi.

OBJECTIVES: The aim of this study was to compare the effects of lidocaine alone and those of morphine or tramadol when added to lidocaine for intravenous regional anesthesia (IVRA) on tourniquet pain, the onset and regression time of motor and sensory block, the level and duration of analgesia, and analgesic consumption. METHODS: After institutional approval and informed consent, 90 patients scheduled for forearm or hand surgery were enrolled and randomly assigned to one of three groups for administration of either 0.5% lidocaine (Group L), 0.5% lidocaine with 1.5 mg.kg(-1) tramadol (Group LT), or 0.5% lidocaine with 0.1 mg.kg(-1) morphine (Group LM) in a volume of 40 ml. The onset and duration of sensory and motor blocks, duration of analgesia and proximal and distal tourniquet, time to first pain medication, visual analog scale (VAS) scores, analgesic requirements in 24 hours, vital signs, and side effects were recorded. RESULTS: Sensory block onset time was significantly shorter in Group LM compared with the other groups and also in Group LT compared to Group L. In addition, sensory block regression time was significantly shorter in Group L than in Group LM (p<0.05). There was a significant increase in VAS scores at the postoperative 4th and 5th hr in Group L (p<0.05). Mean arterial blood pressure was significantly reduced in Group LM at the time of tourniquet deflation (p<0.05). CONCLUSION: IVRA with lidocaine and morphine or tramadol improves postoperative analgesia and sensory block. However, these combinations provide no advantage on tourniquet pain, motor block quality, analgesia duration or analgesic consumption.

Response to delayed fluid therapy in crush syndrome.

BACKGROUND: Although early treatment is valuable in the prognosis of crush syndrome, the diagnosis and treatment of many victims are inevitably delayed in major disasters. PATIENTS AND METHODS: Among the 38 victims of the Marmara earthquake with crush injury, 27 were diagnosed as crush syndrome on the basis of findings of acute renal failure. Intensive intravenous fluid treatment was started in all patients on admission. Of these 27 patients, 10 required dialysis treatment while 17 did not. The laboratory data on admission were evaluated and compared between the two groups. RESULTS: The mean admission time of 27 patients was 46.5 +/- (SE) 3.08 h. There was no significant difference between the dialysis and the nondialysis groups with regard to patient's age, trapped time or admission time. A significantly higher number of patients had crush injury in more than one extremity in the dialysis group. The dialysis group had significantly lower systolic blood pressure, central venous pressure but a higher heart rate together with higher levels of serum urea nitrogen, creatinine, creatinine kinase, C-reactive protein, fibrinogen on admission compared to the nondialysis group. CONCLUSION: Our results suggest that even delayed application of aggressive specific fluid treatment under close monitoring may prevent the development of established acute renal failure.