Anaesthesia praCtice for Caesarean dElivery Snapshot Study (ACCESS): Protocol and baseline characteristics of registered centres.

BACKGROUND: Specific guidelines to manage caesarean delivery anaesthesia are lacking. A European multicentre study, ACCESS investigates caesarean delivery anaesthesia management in European centres. In order to identify ACCESS participating centres, a registration survey was created. OBJECTIVE: The aim of the current report is to describe the characteristics of ACCESS study participating centres, the rationale for the ACCESS study and the study methodology. DESIGN AND SETTING: The ACCESS study is a European multicentre cross-sectional study to describe anaesthesia management for caesarean delivery (CD) using a snapshot (2-week) design. The ACCESS registration survey gathered: contact details for National Coordinators (NC); Lead Investigators (LI) per centre; centre annual CD volume; expected no. of CD during 2-week snapshot window; centre practice information; data collection language. The ACCESS registration survey was launched July 2022 (Google Forms, Google Inc., Mountain View, CA, USA) and distributed through personal connections, national and international societies, social media networks, during Euroanaesthesia 2023, through the European Society of Anaesthesiology and Intensive Care newsletter. RESULTS: The ACCESS registration survey identified Lead Investigators for 418 centres, in 32 countries, representing an anticipated number of 15,073 CD cases over the planned 12-month study period. A median (range) of 20 (2 to 400) CD cases are anticipated per centre during the 2-week snapshot window. Most 366/418 (87.6%) centres are small, ≤2000 annual CD cases, 42 are medium 2000-5000 cases and 10 are large, ≥5000 annual CD cases. Registered centres reported in 134 (32.0%) centres that anaesthesia for caesarean delivery is performed mostly by a specialist obstetric anaesthesiologist. CONCLUSION: The ACCESS registration survey revealed variability in volume and CD practice as well as training-levels and staffing among European countries. The ACCESS study (https://www.access-study.org/) aims to generate practice data to guide CD anaesthetic management strategies.

An Effective Technique in Treatment of Femoral Neck Fractures - Ostheosynthesis under Double Fluoroscopic Guidance.

PURPOSE OF THE STUDY The most commonly used technique for fixation of the femoral neck fractures is percutaneous osteosynthesis with cannulated screw under fluoroscopy guidance. Osteosynthesis performed under single-fluoroscopic guidance requires continuous repositioning the fluoroscope to obtain biplane imaging. This study aimed to evaluate whether there is a statistically significant difference between the osteosynthesis procedures performed under guidance of single-fluoroscopy and double fluoroscopy with respect to radiation emission safety and treatment parameters for fixation of femoral neck fractures. MATERIAL AND METHODS This retrospective study included 35 patients operated for femoral neck fracture between December 2013 and October 2017. Osteosynthesis was performed in 21 of these patients using cannulated screw under guidance of single-fluoroscopy whereas other 14 patients underwent same type of osteosynthesis assisted by double-fluoroscopy. The parameters of these two groups such as duration of surgery preparation, duration of the surgery, duration of radiation exposure, collo-diaphyseal angle and Harris hip score values were recorded. RESULTS No significant difference was found between the groups regarding time for surgery preparation (p > 0.05). On the other hand, duration of surgery and overall duration of radiation exposure were found 14 (p < 0.05) and 15 (p < 0.05) minutes shorter in the double-fluoroscopy group, respectively. No significant difference was found between the groups in terms of collo-diaphyseal angle and Harris hip score values (p > 0.05). CONCLUSIONS Use of double-fluoroscopy significantly reduces time of surgical duration and also level of radiation exposure in surgery of femoral neck fractures. Key words:double fluoroscopy, femoral neck fractures, radiation, osteosynthesis, cannulated screw.

Retrograde intrarenal surgery without fluoroscopy: Is it possible? A randomized prospective study, an extraordinary experience. / Cirugía retrógrada intrarrenal sin fluoroscopia: ¿es posible? Estudio prospectivo aleatorizado, una experiencia extraordinaria.

OBJECTIVES: The aim of this study was to evaluate the role of the use of fluoroscopy in patients undergoing retrograde intrarenal surgery and the effect on surgical outcomes. MATERIAL AND METHODS: The patients who were admitted to our center with the diagnosis of kidney stones were divided into 2groups. In group 1, routine fluoroscopy was used in all cases (n: 58). In group 2, the same procedure was performed without fluoroscopy (n: 67) and the results of the 2groups were compared. RESULTS: There were no statistically significant differences between the 2groups in terms of operation time, stone-free rate, complication rate, need for analgesic and re-treatment requirement and Visual Analogic Scale score. CONCLUSION: The use of fluoroscopy does not alter the complication frequency and stone-free rate. We think that the use of fluoroscopy is not mandatory in cases in which renal pelvis access is achieved especially with semirigid ureteroscopy and that unnecessary fluoroscopy increases radiation exposure.

Different preloading protocols with constant ephedrine infusion in the prevention of hypotension for elective cesarean section under spinal anesthesia.

Ninety ASA I or II parturients were randomly allocated to three groups: group 10RL, 15RL and 20RL to receive 10, 15 and 20 mL/kg of Ringer's lactate (RL) respectively within 15 minutes (min) before the spinal block. Spinal anesthesia was performed with hyperbaric bupivacaine 12 mg, morphine 100 microg and fentanyl 10 microg. The operating table was tilted to the left and an IV infusion of ephedrine of 3 mg/min was immediately started and continued until umbilical cord clamping in all groups. Hypotension was defined as a drop in mean arterial pressure (MAP) of more than 20% from baseline : this was treated with 10 mg ephedrine IV. The incidence of hypotension was 60%, 36.7% and 13.4% in group 10RL, 15RL and 20RL, respectively (p<0.05). Additional ephedrine dose was the lowest in group 20RL compared to the other groups (p<0.05). The total amount of ephedrine was 49.9 +/- 13.5, 46.4 +/- 13.4 and 38.4 +/- 8.5 mg in group 10RL, 15RL and 20RL, respectively (p <0.05). The incidence of nausea and vomiting in group 20RL was significantly less than in group 10RL (p = 0.02). It was concluded that preloading with 20 mL/kg of RL prior to spinal anesthesia followed by constant ephedrine infusion 3 mg/min after spinal block reduced the incidence of hypotension and of nausea and vomiting and decreased the total amount of ephedrine.

Anesthesia for cesarean delivery in the term pregnant following acute onset severe intracranial superior sagittal sinus thrombosis.

Intracranial venous thrombosis is rarely seen prior to delivery. We present our anesthetic management of a term parturient with an acute onset severe superior sagittal sinus thrombosis urgently referred to us. General anesthesia was performed in order to avoid potential increased risk of morbidity after spinal anesthesia in this particular parturient.

Survey of Turkish practice evaluating the management of postdural puncture headache in the obstetric population (1).

Many surveys and meta-analysis concerning the management of postdural puncture headache (PDPH) in the obstetric population were published in the literature. Therefore, we aimed to determine the current practice and ideas in the management of PDPH in the Turkish obstetric population and to provide awareness of the responders about new solutions with a survey. The response rate was 70%. The management strategies against accidental dural puncture during epidural insertion were to leave the catheter in situ as a spinal catheter (36%, n = 28) or to re-site it at a different level (64%, n = 50). Although these results might reflect the current practice of this small sample, in order to follow the changes in these strategies and to catch almost a standard approach for the prevention and management of PDPH which is a serious complication affecting morbidity in this particular population, further surveys including most of the centers are required.

Efficacy of patient-controlled epidural analgesia after initiation with epidural or combined spinal-epidural analgesia.

BACKGROUND: The aim of the present study was to compare the efficacy of patient-controlled epidural analgesia after initiation with either epidural or combined spinal-epidural analgesia. METHODS: Forty ASA I parturients at 37-42 weeks' gestation and cervical dilatation <6 cm were randomly allocated to receive either epidural analgesia (group EA) or combined spinal-epidural analgesia (group CSEA). Analgesia was initiated with a 7-mL epidural bolus 0.1% bupivacaine containing fentanyl 50 mug (group EA, n=20) or with intrathecal fentanyl 20 mug (group CSEA, n=20). In both groups, analgesia was provided by a 5-mL bolus on demand via PCEA with a 10-min lock-out interval and a 15-mL/h limit. RESULTS: No significant differences were observed in the rate of cervical dilatation, delivery type or duration of delivery between the groups. The time to first analgesic demand was shorter in the CSEA than in the EA group. Total bupivacaine dose was comparable in both groups, but total fentanyl dose in group CSEA was significantly lower than that of group EA because of the initial dose used for the induction of EA and CSEA. The incidence of pruritus in group CSEA was significantly higher than in group EA. CONCLUSION: Both regional analgesia techniques followed by demand-only PCEA provided efficient pain relief for labor without changing the duration of labor or rate of cesarean section.

Use of BIS monitor during anaesthesia of a narcoleptic patient for avoiding possible delayed emergence.

Anaesthesia for a narcoleptic patient is not a common practice of anaesthesioligists' daily working life. Therefore special problems related to narcolepsy should be considered pre-, peroperatively and during emergence. The aim of presenting this case report is to emphasize the importance of BIS monitor use in a narcoleptic patient undergoing surgery under general anaesthesia to avoid possible prolonged emergence.

Temporal variation of oxidant stress in critically ill patients.

AIM: Our aim was to investigate indicators of lipid peroxidation via observing temporal changes or daily fluctuations in cytoprotective enzymes such as superoxide dismutase (SOD) and glutathione peroxidase (GSH-PX), and serum components possessing antioxidant activity against free radicals and malondialdehyde (MDA) such as uric acid. This study was conducted in a small number of critically ill patients versus healthy volunteers in order to design an effective antioxidant therapy regimen under oxidative stress. METHODS: Six critically ill patients and 6 young healthy volunteers were recruited. Blood samples were collected 6 times a day with 4 h intervals starting from 8 a.m. From the blood samples, SOD and GSH-PX activities and uric acid and MDA levels were determined. One-way ANOVA and unpaired t-test were used to assess differences within and between the groups, respectively. A two dimensional table curve cosine formulation was performed to elucidate rhythmycity. RESULTS: No significant differences were found in SOD and GSH-PX activities or uric acid levels within the 24 h period or between the groups. MDA levels were significantly higher in the study group at 8 p.m. than that of control group (P<0.05), but no significant difference was found within the 24 h period. We showed that GSH-PX activities in control and study groups revealed temporal variation, whereas uric acid levels varied temporally only in the study group. CONCLUSION: We concluded that there are signs of oxidative stress in ICU patients that vary in time but further studies are required in order to design appropriate antioxidant treatments.

Prevention strategy for post dural puncture headache.

We report the anesthetic management of a parturient after an unintentional dural puncture while performing epidural anaesthesia for caesarean section and the strategy to prevent postdural puncture headache (PDPH). We injected the cerebrospinal fluid (CSF) back into the subarachnoid space and then administered intrathecal 1.5 mL 0.5% hyperbaric bupivacaine and fentanyl 20 microg to maintain CSF volume via epidural needle. The epidural catheter was inserted following re-identification of the epidural space for possible epidural top-up requirement and postoperative pain relief. After adding 3 mL of 0.5% isobaric bupivacaine via epidural catheter, sensory block level reached at T4 bilaterally. No PDPH was observed.

An unmasked neurological pathology (schwannoma) following spinal anesthesia.

A neurological deficit occurred following spinal anaesthesia that unmasked a relatively important neurological pathology. Spinal anesthesia was performed between L3 and L4 by midline approach at the first attempt. Postoperative clinical examination of the patient showed sensory loss below the T5 segment. Whenever new neurological signs are seen after regional anesthesia, further investigations should be done immediately for differential diagnosis. - ÖZET - Spinal anestezi sonrasi gelisen oldukça önemli bir nörolojik patolojiyi kapsayan olgu sunuldu. Spinal anestezi ilk girisimde L3-4 arasindan orta hattan gerçeklestirildi. Postoperatif klinik muayenesinde T5 segmentinin altinda duyusal kayip tespit edildi. Rejyonel anestezi sonrasi ne zaman yeni nörolojik bulgular gözlenirse ayirici tani için hemen ileri tetkikler yapilmalidir.

Interaction of lidocaine with reactive oxygen and nitrogen species.

BACKGROUND AND OBJECTIVE: To investigate the ability of lidocaine to inhibit reactive oxygen and/or nitrogen species generation by either human leukocytes or cell-free systems via luminol- and lucigenin-enhanced chemiluminescence. METHODS: Venous blood was obtained from healthy volunteers and leukocytes were isolated, from which chemiluminescence was generated. Also, chemiluminescence, induced by H(2)O(2), HOCl, peroxynitrite or ferrous iron, was generated in cell-free systems. RESULTS: Lidocaine produced a concentration-dependent inhibition in chemiluminescence generated by leukocytes (92 +/- 1%, 1 mM). In cell-free experiments, lidocaine (1 mM) markedly inhibited chemiluminescence of xanthine-xanthine oxidase (24 +/- 3%), while it slightly suppressed hypochlorous acid-induced chemiluminescence (9 +/- 2%). Peroxynitrite-induced luminol- and lucigenin-enhanced chemiluminescence were also inhibited by lidocaine at 1 mM (19 +/- 3% and 48 +/- 8%, respectively). Lidocaine did not affect chemiluminescence generated by FeSO(4). However, lidocaine produced a biphasic effect on H(2)O(2)-induced chemiluminescence (37 +/- 5% inhibition at 0.01 mM and 61 +/- 17% activation at 1 mM). CONCLUSIONS: Lidocaine can elicit direct scavenging activity at high concentrations that might be important at or near the site of injection in local anaesthetic use.

Effects of prilocaine and articaine on human leucocytes and reactive oxygen species in vitro.

BACKGROUND: The aim of this study was to investigate the ability of local anaesthetics to inhibit reactive oxygen and nitrogen species generated by either stimulated human leucocytes or cell-free systems using luminol chemiluminescence (CL). METHODS: Free radical generation was stimulated in leucocyte assay by formyl-methionyl-leucyl-phenylalanine (FMLP, 2 microM). In cell-free experiments, hydrogen peroxide (H2O2) 3.5 mM, sodium hypochloride 5 microM, ferrous sulphate (FeSO4) 40 nM, peroxynitrite 50 nM and xanthine 0.1 mmol l(-1) plus xanthine oxidase 0.25 U ml(-1) were used to produce H2O2, hypochlorous acid (HOCl), hydroxyl radical, peroxynitrite and superoxide-induced CL, respectively. RESULTS: Prilocaine inhibited FMLP-induced CL in leucocytes (94+/-1%, at 1 mM), whereas articaine showed an activation (59+/-7%) at high concentration (1 mM) and inhibition (13+/-6%) at low concentration (0.1 mM). In cell-free experiments, prilocaine (22+/-6%, at 1 mM) and articaine (85+/-1%, at 1 mM) caused concentration-dependent inhibition in xanthine-xanthine oxidase-induced CL. Although articaine had no effect on H2O2-induced CL, prilocaine significantly attenuated the H2O2 signal (97+/-0.3%, at 1 mM). Prilocaine (99+/-0.04%, 1 mM) and articaine (70+/-6%, 1 mM) markedly inhibited HOCl-induced CL, whereas these drugs had no effect on FeSO4-induced CL. Articaine inhibited peroxynitrite CL (63+/-6%, 1 mM), but prilocaine did not produce any depression on this signal. CONCLUSION: Prilocaine interacted with superoxide, HOCl and H2O2, whereas articaine reacted with superoxide, HOCl, and peroxynitrite. The direct scavenging properties of these drugs might be involved in the inhibition observed in leucocyte assay and could provide experimental support for investigating the potential benefit of using these local anaesthetics in patients presenting pathologies associated with free radical reactions.

Epidural anaesthesia for Caesarean section in a patient with Devic's Syndrome.

The anaesthetic management of a 29-year-old paraplegic woman suffering from Devic's Syndrome scheduled to undergo Caesarean section under epidural anaesthesia is presented. The case is discussed with particular reference to the risk of autonomic hyperreflexia.

Seasonal variation in the effect of a fixed dose of heparin on activated clotting time in patients prepared for open-heart surgery.

We investigated the effect of an injected bolus of 5 mg kg(-1) heparin at one circadian stage (08:30 to 11:00) on blood coagulation during different months of the year. Activated clotting times (ACTs) were assessed before and 5 min after heparin dosing to ensure extracorporeal circulation during open-heart surgery. The ACT data of 1083 presumably day-active Turkish patients (816 men and 267 women, mostly older than 46 years) who underwent coronary bypass surgery between 08:30 and 11:00 in the years from 1994 to 1997 were analyzed for annual rhythmicity. The ACT values obtained just before and 5 min after heparinization were subjected to cosinor analysis using a 365.25-day period to assess seasonality in basal ACT level and heparin effect. A small-amplitude annual rhythm with a wintertime peak was documented in the morning ACT in the group of 1083 patients. Rhythms of similar magnitude and staging were also detected in heparin effect on ACT in the 1083 patients and in subgroups categorized by gender. Circannual rhythmicity in the heparin effect on ACT was also documented in the elderly (> or = 45 years old), but not young (18-45 years old) patients. The annual mean effect of heparin on the ACT was statistically significantly greater in younger than older patients. The relatively low-amplitude circannual rhythm in heparin effect on ACT (approximately 10% of the annual mean) is not viewed as being meaningful in patient preparation for bypass surgery for the 5 mg kg(-1) level of heparin dose.

Effect of high-dose lidocaine treatment on superoxide dismutase and malon dialdehyde levels in seven diabetic patients.

BACKGROUND AND OBJECTIVES: We report on the use of intravenous (IV) high-dose lidocaine to relieve diabetic neuropathic pain, and the technique's effects on clinical measures of lipid peroxidation. METHODS: Under continuous electrocardiogram monitoring, IV lidocaine (5 mg kg(-1) in 100 mL saline) was administered over 30 minutes to 7 non-insulin-dependent diabetic patients suffering from neuropathic pain who reported increased pain within the preceding 6 months. This treatment was performed once a week for 1 month. Blood samples were collected from the contralateral limb to determine plasma superoxide dismutase (SOD) and malondialdehyde (MDA) levels on admission and following the final lidocaine administration. RESULTS: Plasma MDA concentrations significantly decreased after the final IV lidocaine treatment (P < .05, paired t-test), whereas SOD levels did not show a statistically significant difference compared with baseline levels. CONCLUSIONS: High-dose lidocaine treatment lessens MDA levels, a marker of free-radical-mediated cell damage. This suggests that one of lidocaine's mechanism of action may be its effect on oxygen free radicals, which in turn impacts lipid peroxidation.

Does remote organ ischaemia trigger cardiac preconditioning during coronary artery surgery?

The aim of this study is to provide biochemical evidence of the occurrence of cardiac preconditioning via remote organ ischaemia on the patients undergoing coronary artery surgery. Eight male patients were randomly allocated into two groups. Blood samples were collected via coronary perfusion catheter immediately before cardiopulmonary bypass (point 0), prior to declamping aorta (point 1) and 5 min after declamping the aorta (point 2) to determine creatinine phosphokinase (CPK), CPK-MB and lactate dehydrogenase (LDH) levels in the control group. A tourniquet wrapped around the right upper extremity of the patient was inflated and deflated twice to perform 3 min of ischaemia separated with 2 min of reperfusion in the preconditioning group. Blood samples were withdrawn as described for the control group. Only LDH levels at point 2 were found to be significantly higher than the control group's. These data implied that preconditioning appeared to protect myocardium by enhancing anaerobic glycolysis.

Cerebral hypoperfusion after cardiac surgery and anesthetic strategies: a comparative study with high dose fentanyl and barbiturate anesthesia.

BACKGROUND: Postoperative delirium is a common sequel of cardiopulmonary bypass that is hard to diagnose correctly, difficult to predict and almost impossible to prevent and to treat. The aim of this study is to evaluate the frequency of postoperative cognitive disorders and cerebral hypoperfusion in patients receiving either high dose fentanyl or thiopentone anesthesia in cardiac surgery. METHODS: 50 unpremedicated patients, Class IIb-NYHA (25 patients in each group suffering from single critical LAD disease) undergoing elective coronary artery bypass grafting surgery were randomly allocated into two groups either to receive fentanyl 50 microg/kg with diazepam 0.1 mg/kg (Group 1) or thiopentone 7 mg/kg (Group 2) for the induction of anesthesia. Anesthesia was maintained with fentanyl 2 microg/kg/hr and diazepam 0.05 mg/kg/hr infusion in Group 1 throughout the procedure. In Group 2, it was maintained with enflurane 0.7-1.5% before and after cardiopulmonary bypass (CPB) and with thiopentone 3 mg/kg/hr infusion during CPB. Neuropsychiatric evaluation (STAI-T, min mental state examination-MMSE and Zung tests), EEG and SPECT rCBF (Single Photon Emission Computed Tomography Regional Cerebral Blood Flow) studies were performed preoperatively, early and late postoperatively. The patients that were diagnosed to have postoperative cerebral hypoperfusion also underwent computed tomography scanning postoperatively. RESULTS: Eleven patients (9 from fentanyl and 2 from thiopentone group) were diagnosed to have cerebral hypoperfusion with respect to SPECT rCBF studies. Seven of these patients (5 from fentanyl and 2 from thiopentone) were diagnosed to be in a state of delirium clinically with MMSE tests. CONCLUSION: High dose fentanyl anesthesia causes significant predisposition to postoperative cerebral hypoperfusion when compared with barbiturate anesthesia in cardiac surgery. Hypoperfusion as demonstrated by SPECT rCBF studies may play an important role in the pathophysiology of mental disorders, i.e., postoperative delirium.