Effect of Remote Ischemic Preconditioning in Total Knee Arthroplasty on Thiol-Disulfi de Balance: a Randomized Controlled Study.

PURPOSE OF THE STUDY The purpose of this study was to minimize tourniquet-induced ischemia-reperfusion injury (IRI) in total knee arthroplasty (TKA) surgery using the remote ischemic preconditioning (RIPC) model, as well as to assess antioxidant balance with thioldisulfi de homeostasis (TDH). The secondary goal is to evaluate the impact of RIPC on TKA clinical outcomes. MATERIAL AND METHODS Patients in the ASA I-III group who underwent elective TKA were enrolled in this prospective, randomized, double-blind clinical research. TDH parameters were measured individually in groups with (Group I) and without (Group K) RIPC at the following times: preoperative (T0), right before the pneumatic tourniquet was opened (T1), 1 (T2), 6 (T3), and 24 (T4) hours after it was opened. In addition, at 3-hour intervals, the postoperative pain level was assessed using a visual analog scale (VAS). RESULTS This study included 60 cases (Group K; n=30, Group I; n=30). Both groups had equal native thiol, total thiol, disulfi de levels, disulfi de/native thiol, disulfi de/total thiol, and native thiol/total thiol ratios (p>0.05 for each). The change in native thiol, total thiol, and disulfi de values at T0 and T4 periods, however, was not statistically signifi cant for Group K (p=0.049, p=0.047, p=0.037, and p=0.217, p=0.191, p=0.220, respectively). At the 15th hour, VAS values in group I were considerably lower than in Group K (p=0.002). DISCUSSION This prospective, randomized, controlled trial examined how RIPC affected tourniquet-induced IRI-induced oxidative stress in TKA surgery. Lower native, total, and disulfi de levels at each postoperative time point were signifi cant. RIPC may reduce tourniquet-induced IRI-induced oxidative stress and TDH in TKA surgery. RIPC also reduced postoperative discomfort. CONCLUSIONS Our fi ndings suggest that RIPC may protect against the oxidative stress caused by IRI during limb surgery with a tourniquet and improve postoperative clinical outcomes. Key words: remote ischemic preconditioning, ischemia-reperfusion injury, thiol-disulfi de balance, oxidative stress, total knee arthroplasty.

Comparison of the effects of low-flow and normal-flow anesthesia on intracranial pressure, cerebral oxygenation and bispectral index in laparoscopic cholecystectomy operation.

OBJECTIVE: Pneumoperitoneum in laparoscopic surgeries can raise intracranial pressure (ICP). Low-flow anesthesia offers benefits such as improved clearance, temperature preservation, fluid reduction, cost savings, and lower emissions. However, the impact of low-flow anesthesia on ICP during laparoscopic cholecystectomy remains unclear. This study aimed to compare the effects of low-flow anesthesia (0.75 l/min) to those of normal-flow anesthesia (1.5 l/min) on optic nerve sheath diameter (ONSD) in laparoscopic cholecystectomy patients. PATIENTS AND METHODS: A total of 80 elective laparoscopic cholecystectomy patients were included in the study. Patients were randomly allocated (1:1) into two study groups: a low-flow anesthesia group and a normal-flow group. ONSD, BIS, left and right rSO2, SAP, DAP, MAP, HR, SpO2, EtCO2, peak inspiratory pressure (P-Peak), Mini-Mental State Exam (MMSE), and duration of surgery were recorded. RESULTS: The results showed that low-flow anesthesia (0.75 l/min) during laparoscopic cholecystectomy had a preventive effect on the increase in ONSD at 30 minutes (T4) into the operation (p = 0.014). BIS values of left and right rSO2 during the preoperative and intraoperative periods were similar. CONCLUSIONS: In conclusion, low-flow anesthesia during laparoscopic cholecystectomy may benefit ICP by preventing an increase in ONSD.

Evaluation of the association between the optic nerve sheath diameter and extracorporeal life support time during cardiac surgery in newborns.

OBJECTIVE: Congenital heart disease (CHD), a birth defect, is a major cause of neonatal mortality; however, improvements in surgical procedures and medical treatments have resulted in decreased mortality rates. Nonetheless, postoperative morbidity, particularly cerebral dysfunction, remains an issue in patients receiving extracorporeal life support (ECLS) for cardiac surgeries. Herein, we aimed to assess the association between optic nerve sheath diameter (ONSD) and ECLS time in newborns receiving ECLS for cardiac surgery. PATIENTS AND METHODS: We enrolled 25 newborn patients who received ECLS for cardiac surgery at our hospital. ONSD was measured at four different time points during the surgery: baseline (T1), 15 min after cross-clamping (T2), after displacement of cross-clamping (T3) and at the end of the surgery (T4). Furthermore, the ECLS time, aortic cross-clamp time, and surgery time were recorded. RESULTS: The regression analysis revealed a significant association between ONSD and ECLS time, cross-clamp time and surgery time. The correlation analysis showed strong associations between baseline ONSD and ONSD at T2, T3, and T4. Moreover, ONSDs significantly increased at T2 compared with those at baseline during cardiac surgery. CONCLUSIONS: Our findings suggest an association between ONSD and ECLS time in newborns receiving ECLS for cardiac surgery. Monitoring ONSD may provide valuable information about intracranial pressure changes in these patients.

The relationship between serum estrogen concentration and post-dural puncture headache: a retrospective study.

OBJECTIVE: Post-Dural puncture headache (PDPH) is a severe and undesirable complication for the patient and anesthesiologist. PDPH is more common in female patients. However, its relationship with plasma estrogen levels has not been demonstrated. This study aimed to investigate the relationship between estrogen levels and PDPH in patients who underwent spinal anesthesia for in vitro fertilization (IVF) with supraphysiological estrogen levels. PATIENTS AND METHODS: In this retrospective study, the data of patients between the ages of 18-45 with the following characteristics were included in the study: those who underwent IVF procedure between January 2021 and August 2022, in the ASA I-II risk group, and who underwent spinal anesthesia using a 25 G Quinke-tipped spinal needle at the L3-L4 or L4-L5 vertebra levels. The 48 patients in the study were in two groups according to their estradiol values: 'Supra physiological estradiol levels' (Group I=24 patients) and 'Normal estradiol levels' (Group C=24 patients). The relationship between PDPH and estrogen, progesterone, spinal needle diameter, and patient demographic characteristics were evaluated. RESULTS: The estrogen and progesterone levels of patients in Group I were higher than in Group C (p<0.001 and p<0.001, respectively). PDPH was present in 6 (25%) patients in Group I and 5 (20.8%) patients in Group C (p=0.731). There was no significant correlation between PDPH and estrogen and progesterone levels (p>0.05). CONCLUSIONS: Since there is no relationship between the supraphysiological estrogen level and PDPH, high serum estrogen level should not be considered as an additional risk factor for PDPH in the decision of anesthesia type for IVF procedure.

Does the menstrual phase affect gastric emptying? Prospective, observational study.

OBJECTIVE: Pulmonary aspiration of gastric content is a serious complication of anesthesia. It is unclear what effects different parts of the menstrual cycle have on how long it takes for the stomach to empty. This prospective observational study assessed the relationship between menstrual cycle phases and gastric emptying using ultrasonography (USG) in volunteers of reproductive age. PATIENTS AND METHODS: Between days 8-10 of the menstrual cycle in the follicular phase and days 18-20 of the luteal phase, a total of 24 healthy volunteers received four stomach USG procedures. In both phases, the gastric antrum was evaluated with USG in the right lateral decubitus position after fasting for 10 hours, followed by 2 hours of fasting after liquid intake and 6 hours of fasting after solid food intake. The gastric content, gastric antrum area, and estimated gastric volume determined whether the stomach was full or empty. RESULTS: A full stomach was detected in 8 (8.3%) out of 96 measurements performed on the volunteers. After liquid food intake, a full stomach was detected in 2 subjects in the luteal phase, while all the subjects had an empty stomach during the follicular phase (p=0.500). After solid food intake, a full stomach was detected in 6 subjects in the luteal phase, and again, all subjects had an empty stomach during the follicular phase (p=0.031). CONCLUSIONS: Ultrasound assessment of gastric volume in volunteers of reproductive age has shown that gastric emptying of solid foods is slowed during the luteal phase of the menstrual cycle.

Transcutaneous electric acupoint stimulation reduces rocuronium injection-related pain: a prospective randomized controlled study.

OBJECTIVE: Various approaches have been suggested to reduce the pain and discomfort associated with rocuronium injection. This randomized controlled trial aimed at exploring the effectiveness of transcutaneous electrical acupoint stimulation (TEAS), a non-invasive modality to reduce the pain associated with rocuronium injection. PATIENTS AND METHODS: 60 patients undergoing elective general anesthesia were recruited and randomly allocated to the TEAS or placebo TEAS (no electrical output) groups. TEAS consisted of 30 min of stimulation at a frequency of 2/100 Hz and an intensity of 6-9 mA on Hegu (LI4) and Neiguan (PC6) before anesthesia induction. A blinded observer evaluated the pain using a 4-point pain scale. RESULTS: The overall incidence of rocuronium injection-related pain was significantly lower in the TEAS group than that in the placebo TEAS group (40% and 86.7%, respectively). The incidence of no or mild pain was significantly higher in the TEAS group (100%, p<0,001) group than that in the placebo TEAS group (50%). CONCLUSIONS: Pretreatment with TEAS effectively reduced the frequency and severity of pain associated with rocuronium injection.

Effects of smoking on thiol/disulfide homeostasis.

OBJECTIVE: Cigarette smoking is an important risk factor for many diseases. This study aimed to evaluate whether cigarette smoking is associated with changes in the thiol/disulfide homeostasis (TDH), a novel biomarker of systemic oxidative stress. PATIENTS AND METHODS: Eighty-four smokers and 86 non-smoking healthy volunteers were enrolled. Serum native thiol, disulfide and total thiol levels, disulfide/native thiol, disulfide/total thiol, and native thiol/total thiol ratios were analyzed using a new colorimetric method. Carbon monoxide (CO) levels were measured by a piCO smokerlyzer instrument. RESULTS: The native, total, and native/total thiol levels of smoking patients were significantly lower (p<0.001 for each), and disulfide, disulfide/native thiol, and disulfide/total thiol levels were significantly higher in smokers than the healthy controls (p<0.001 for each). The CO levels of all study participants were negatively correlated with native thiol (r= -0.627, p<0.001), total thiol (r= -0.569, p<0.001), native thiol/total thiol (r= -0.515, p<0.001), and positively correlated with disulfide (r=0.398, p<0.001), disulfide/native thiol (r=0.515, p<0.001) and disulfide/total thiol (r=0.515, p<0.001) levels. CONCLUSIONS: To our knowledge, this investigation is the first in the literature that investigated TDH in cigarette smokers. Our results show that cigarette smoking may lead to oxidative stress and TDH shifts through disulfide side compared to the healthy group. Further studies with larger sample size are needed to confirm our results for showing the changes in TDH to contribute to the clinical practice.

The predictive effect of initial complete blood count of intensive care unit patients on mortality, length of hospitalization, and nosocomial infections.

OBJECTIVE: The mean platelet volume (MPV) can be used as an indicator of platelet activation. However, it has been shown that the platelet/lymphocyte ratio (PLR) can provide useful predictive information about inflammation and aggregation pathways. The neutrophil/lymphocyte ratio (NLR) may also be helpful as a marker of systemic or local inflammation. The main objective of this study evaluated to unselected critically ill patients the relationship of initial MPV, NLR, and PLR with mortality, length of hospitalization, and the risk of developing nosocomial infections in ICU patients. PATIENTS AND METHODS: In this retrospective study, we evaluated consecutive patients at our tertiary nine-bed ICU. One hundred seventy-three patients who were followed up during a 1-year period were included. RESULTS: MPV levels were found to be higher in patients who died in the hospital (p = 0.05). In addition, there was a significant positive correlation between expected mortality rate and MPV among non-survivors (p = 0.009). NLR levels were higher among non-survivors, but this difference was not statistically significant (p = 0.435). PLR levels were similar between non-survivors and survivors (p = 0.173). The initial NLR and PLR were significantly higher in patients with nosocomial infections. NLR and PLR had a significant positive correlation with length of hospitalization (p = 0.006 and p = 0.027, respectively). CONCLUSIONS: In our study, we found that high PLR and NLR may be indicators for the development of nosocomial infections. Moreover, the length of hospitalization may be prolonged in patients with high PLR and NLR.

The effect of preeclampsia on the skin to subarachnoid distance in spinal anesthesia.

BACKGROUND: Preeclampsia is characterized by increased extracellular fluid which manifests as generalized edema due to endothelial injury and subsequent capillary leak. Therefore, preeclampsia may lead to increased skin to subarachnoid distance (SSD) which may influence daily clinical practice in this particular gravid population. METHODS: Age- and height-matched gravidas with and without preeclampsia were enrolled prospectively at an allocation ratio of 1:4. Spinal anesthesia (SA) was performed in a sitting position by a mid-line approach at the L3-L4 interspace using a 25-gauge Quincke spinal needle. An internal pilot study was performed to determine the sample size. When the protocol violations were excluded, 146 gravidas were included in the study (25 preeclamptics and 121 normotensive controls) for final analysis. RESULTS: On average, SSD was 0.89 cm greater in preeclamptics compared to normotensive controls. Mean values of the SSD in preeclamptic and normotensive control group patients at the L3-L4 interspace were 6.187 ± 0.967 and 5.301 ± 0.834 cm, respectively. SSD was significantly correlated with body weight and body mass index (BMI). The regression formula for the estimation of SSD in preeclamptic gravidas with BMI during SA was SSD = 3.696 + 0.075×BMI. The regression formula for the estimation of SSD in the normotensive control group with BMI during SA was SSD = 3.144 + 0.067×BMI - 0.0001×BMI×BMI. CONCLUSION: Knowing that the SSD is increased in preeclamptics compared to normotensive gravidas may be of value in terms of selecting needle, and providing safe and comfortable anesthesia.