Surgical conditions during FESS; comparison of dexmedetomidine and remifentanil.

To compare dexmedetomidine with remifentanil in functional endoscopic sinus surgery (FESS) in regards to intra-operative bleeding, anesthetic consumption and post-operative recovery. Randomized, double blind study. Tertiary care medical center. Fifty patients with nasal polyposis who had been scheduled for FESS were randomly divided into two groups. In group D (n = 25), dexmedetomidine 1 µg/kg infused intravenous (IV) over 10 min before anesthesia induction, followed by a continuous of 0.7 µg/kg/h infusion during operation. In group R (n = 25), 1 µg/kg remifentanil IV bolus, was administered with induction of anesthesia and continued 0.25-0.50 µg/kg/min during operation. Heart rates, mean arterial pressure, end tidal CO2, end tidal sevoflurane were recorded. The amount of bleeding, surgical field condition for bleeding and the time to reach Aldrete recovery score 9-10 were recorded. Postoperative nausea, vomiting, pain, shivering, sedation were followed up over 24 h. There was no significant difference between groups according to the amount of bleeding during surgery, assessment of surgical field condition, consumption of sevoflurane, scores of postoperative VAS, rates of nausea and vomiting, shivering, demands of additional analgesic medication (P > 0.05). The time to reach Aldrete recovery score 9-10, sedation scores at the postoperative first hour were significantly higher in group D (P = 0.001). We concluded that in comparison to remifentanil, dexmedetomidine during FESS for controlled hypotension is of limited value as it has no additional benefits in terms of control of hypotension and amount of bleeding in the surgical field and it is associated with higher recovery time and first-hour postoperative sedation scores.

The effects of adding ischemic preconditioning during desflurane inhalation anesthesia or propofol total intravenous anesthesia on pneumoperitoneum-induced oxidative stress.

BACKGROUND: The aim of the study was to explore the differences in oxidative stress during anesthesia with desflurane/N2O or propofol/remifentanil in patients undergoing laparoscopic cholecystectomy and additionally to evaluate the differential effects of desflurane and propofol on ischemic preconditioning (IP). MATERIALS AND METHODS: One hundred patients were randomly allocated to four groups. For anesthesia maintenance, the inhalation group (Group I) and the inhalation plus IP group (Group IIP) received desflurane at an end-tidal concentration of 4-6 vol% in oxygen/N2O, and the TIVA group (Group T) and TIVA plus IP group (Group TIP) received infusions of propofol and remifentanil. In Groups IIP and TIP, IP was carried out by 10 min of pneumoperitoneum followed by 10 min of deflation. Preoperative and postoperative plasma total antioxidant status (TAS), total oxidant status (TOS), paraoxonase, stimulated paraoxonase, arylesterase, ceruloplasmin, and myeloperoxidase levels were analyzed; oxidative stress index (OSI) was calculated. RESULTS: When oxidative stress parameters were compared between groups, myeloperoxidase values in Group I were statistically significantly lower compared to Group TIP (p = .004 with Bonferroni's correction). There were no differences between preoperative and postoperative TAS, paraoxonase, stimulated paraoxonase, arylesterase, or ceruloplasmin levels (p > .05). In intragroup evaluations, postoperative paraoxonase and stimulated paraoxonase levels were found to be lower than preoperative values in Group TIP (p = .021 and .012, respectively). CONCLUSION: In laparoscopic cholecystectomy lasting less than 60 min, there were no differences in the measured oxidative stress parameters between maintenance of anesthesia by desflurane/N2O and propofol/remifentanil/N2O. The addition of 10 min IP administration during both anesthesia techniques did not result in additional changes in the analyzed oxidative stress.

Transient neurological symptoms after spinal anesthesia.

PURPOSE: The aim of this study was to investigate the incidence of transient neurological symptoms (TNS) after spinal anesthesia with levobupivacaine, bupivacaine, articaine or lidocaine. METHODS: The patients (n=400) were randomly assigned to receive spinal anesthesia with levobupivacaine, bupivacaine, articaine or isobaric lidocaine. Onsets of sensory and motor block were recorded. On postoperative days 1, 2 and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic agent used. The patients were classified as having TNS if there was pain in the hips, thighs and/or lower limbs following recovery from anesthesia. RESULTS: Time to maximum sensory block was significantly longer in the articaine group than the lidocaine group. The incidence of TNS was much less after spinal anesthesia with levobupivacaine, bupivacaine and articaine than after lidocaine.

Comparison of intrathecal plain articaine and levobupivacaine with fentanyl for Caesarean section.

PURPOSE: Articaine is used as a local anesthetic for outpatient surgery because it offers rapid onset of anesthesia and short duration motor block. Levobupivacaine is often preferred for Caesarean section. We evaluated the anesthetic characteristics of fentanyl-supplemented plain articaine and levobupivacaine for Caesarean section under combine spinal epidural anesthesia. METHODS: Patients undergoing Caesarean section received in random order plain articaine 40 mg (Group A, n=50) or plain levobupivacaine 10 mg (Group L, n=50) mixed with fentanyl 20 µg intrathecally. The onset and duration of sensory and motor block, first analgesic request, and hemodynamic parameters were recorded. RESULTS: Onset times of maximum motor block were longer in Group L than Group A (P=0,001). Time to two-segment regression of sensory block were 70 min for Group A and 90 min group L (P=0.001). Times to complete regression of motor blockade were significantly longer in group L than group A (P =0,001). CONCLUSION: To have a faster onset and shorter duration of spinal anesthesia, we recommend the use of plain articaine for Caesarean section.

Comparison of neck ultrasonography with a pH meter to confirm correct position of nasogastric tube.

PURPOSE: The aim of this study was to compare pH meter and neck ultrasonograph for evaluation of nasogastric tube (NGT) position. METHODS: A total of 35 adult patients who required NGT insertion were included. The NGT was inserted by an anesthetist after endotracheal intubation, and the transducer was placed transversely on the neck, just superior to the suprasternal notch. The passage of the NGT in the esophagus was evaluated by a sonographer, and the stomach was emptied by nasogastric suction. Secretion from inside the NGT was analyzed using a pH meter. The tip of the NGT was accepted as being in the stomach if the pH measured between 1 and 5. Neck ultrasonography was compared with the pH meter analysis for confirmation of NGT position. RESULTS: Ultrasonography was highly sensitive (100% (95% CI 89.6-100%) and specific (97.2% (95% CI 85.4-99.5%) for evaluation of NGT position. The specificity for the pH meter was 100% (95% CI 16.6-100%), while the sensitivity was 76.5% (95% CI 58.8-89.2%). CONCLUSIONS: This study showed that neck ultrasonography is more sensitive than the pH meter for confirmation of NGT position.

A Needle-Free Injection System (INJEX™) with lidocaine for epidural needle insertion: A randomized controlled trial.

OBJECTIVES: Local anesthetic infiltration is also a process of a painful process itself. INJEX™ technology, known as "Needle-free" drug delivery system, was designed for reducing the pain associated with cutaneous procedures. We conducted a prospective, randomized trial to evaluate the application of lidocaine with INJEX™ system and 27-gauge needle. METHODS: A total of 60 consecutive patients were allocated to receive either INJEX group or 27-gauge needle group. Local anesthetic infiltration was applied two minutes before epidural needle insertion. RESULTS: Mean VAS, at the time of local anesthetic injection was 0 for group I and 2 for group II. When the effect of epidural needle insertion was compared, the mean VAS score was one versus two for Group-I versus Group-II, respectively. Lidocaine applied with the INJEX™ system before epidural needle insertion significantly reduced the intensity of pain during that procedure and was least effective the lidocaine applied with the 27-gauge needle and patients felt less pain during at the time of local anesthetic injection in Group-I. CONCLUSION: Needle-free delivery of lidocaine is an effective, easy to-use and noninvasive method of providing local anesthesia for the epidural needle insertion.

Assessment of fetal antioxidant and oxidant status during different anesthesia techniques for elective cesarean sections.

BACKGROUND: We aimed to investigate the effects of general, spinal and epidural anesthesia on fetal total antioxidant status (TAS) and total oxidant status (TOS), and oxidative stress index (OSI) during elective cesarean section in this study. MATERIALS AND METHODS: Forty-seven parturients scheduled for elective cesarean section were randomly allocated into three groups: Group spinal (n = 15), group epidural (n = 17), and group general (n = 15), This prospective randomized study was performed in Faculty of Medicine, Turgut Ozal University, Turkey. After the baby was delivered; TAS, TOS levels, and arterial blood gases parameters were analyzed in an umbilical arterial blood sample. OSI values are calculated by a ratio of TOS to the TAS. RESULTS: The levels of TAS and TOS in umbilical arterial blood sample were not statistically different among three. However, OSI values were significantly different among the three groups (P = 0.042). Median OSI values is 24 (interquartile range [IQR], 2-37) in group spinal, 19 (IQR, 4-44) in group epidural, and 8 (IQR, 4-36) in group general. There was no significant difference in OSI values in the comparison of group spinal with group general and group epidural, but it was significantly lower in group general when compared with group epidural with Bonferroni correction (P = 0.017). Umbilical cord arterial blood gas values (pH, PaCO2, PaO2, SaO2, HCO3, and CtO2), glucose, lactate, and hemoglobin levels were similar in three groups. CONCLUSION: General anesthesia may be more favorable than epidural in those undergoing cesarean section when fetal oxidative status gains importance.

Assessment of nasal mucociliary clearance in anesthetists.

BACKGROUND/AIM: To assess mucociliary clearance in anesthetists who were exposed to waste anesthetic gases occupationally. MATERIALS AND METHODS: The first group consisted of 30 anesthetists who had been working at least 2 years. The control group of 30 subjects was selected from hospital staff with no history of occupational exposure to waste anesthetic gases. Mucociliary clearance time was assessed by measuring the saccharine nasal transit time (SNTT). RESULTS: Thirty-six women and 24 men aged between 25 and 60 years were enrolled in the study. There were no differences between the anesthetist and control groups in terms of age, sex, height, or weight. The median SNTT for the anesthetists (10 min) was longer than that for the control group (8.3 min). The difference was significant (P = 0.025). In addition, there was a significant correlation between the SNTT and the working time (P = 0.02). Furthermore, anesthetists who had worked for 4 years or more had prolonged SNTT compared to those who had worked less than 4 years (P < 0.001). CONCLUSION: The present study demonstrated the impairment of mucociliary clearance in anesthetists. Increasing impairment with increasing working time was also detected.

New hemostatic agent: the effect of Ankaferd Blood Stopper on healing wounds in experimental skin incision model.

AIM: To conduct a histopathological evaluation of the effects of Ankaferd Blood Stopper (ABS) on healing wounds in a rabbit skin incision model. MATERIALS AND METHODS: Incisions were performed on the backs of rabbits. The first incision was allowed to undergo normal secondary healing. ABS (1 mL) was applied to the second incision, which was subsequently allowed to undergo secondary healing. The third incision was sutured. ABS (1 mL) was applied to the fourth incision, which was subsequently sutured. During the wound healing period, the histopathologic signs of ulceration, inflammation, the proliferative phase, and the extent of early remodeling were comparatively evaluated by performing biopsies on days 5, 10, and 30. RESULTS: For all of the ABS-treated wounds, the appearance of the cavities during the early stage and the disappearance of the cavities during the late stage were observed. In addition, on days 5-10, the inflammatory granulation tissue in the ABS-treated wounds was less than in the normal wounds. By day 30, all of the wounds had achieved the same symptomatic state. CONCLUSION: As ABS does not exert any negative effects on wound healing, this agent is a secure and effective method for achieving hemostasis.

The comparison of preincisional peritonsillar infiltration of ketamine and tramadol for postoperative pain relief on children following adenotonsillectomy.

OBJECTIVE: To investigate and compare the effectiveness of preincisional peritonsillar infiltration of ketamine and tramadol for post-operative pain on children following adenotonsillectomy. STUDY DESIGN: Prospective randomized double blind controlled study. METHODS: Seventy-five children aged 3-10 years undergoing adenotonsillectomy were included in study. Patients received injections in peritonsillar fossa of tramadol (2 mg/kg-2 ml), ketamine (0.5 mg/kg-2 ml) or 2 ml serum physiologic. During operation heart rate, oxygen saturation, average mean blood pressures were recorded in every 5 min. Operation, anesthesia and the time that Alderete scores 9-10, patient satisfaction, analgesic requirements were recorded. Postoperatively nausea, vomiting, sedation, dysphagia, bleeding scores were recorded at 0, 10, 30, 60 min and 2, 4, 8, 12, 18, 24h postoperatively. Pain was evaluated using modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at fixed intervals after the procedure (15 min and 1, 4, 12, 16, and 24h postoperatively). RESULTS: The recordings of heart rate, mean arterial pressure, nausea, vomiting, sedation and bleeding scores were similar in all groups (p>0.05). The mCHEOPS scores at 10 min, 30 min, 1h, 8h were significantly lower in both tramadol and ketamine group when compared with control (p<0.05). Use of additional analgesia at 10 min and 18 h were higher in control group than ketamine, tramadol group (p<0.05). Dysphagia scores were significantly lower for both ketamine and tramadol group when compared with control group (p<0.05). mCHEOPS, additional analgesia, dysphagia, patient satisfaction scores were similar in tramadol, ketamine groups (p>0.05). CONCLUSIONS: Preincisional injection of ketamine and tramadol prior to tonsillectomy is safe, effective method and equivalent for post-tonsillectomy pain, patient satisfaction, postoperative nausea, vomiting, dysphagia.

[Cervical epidural steroid injections for symptomatic disc herniations]. / Semptomatik disk hernilerinde servikal epidural steroid uygulamasi

OBJECTIVES: Cervical radiculopathy is widespread in society, and the methods used in the treatment cover a wide range from conservative treatment to surgical treatment. There is not yet a full consensus on the use of invasive approaches for the optimal treatment of radicular pain. However, cervical epidural steroid injection (CESI) has been used in patients with symptoms of cervical discopathy. METHODS: Results of the six-month period of treatment of 58 patients, diagnosed as symptomatic cervical radiculopathy with application of CESI within a one-year period, were evaluated retrospectively. With the patients in a sitting position and with the head flexed, the epidural space was accessed from the C7-T1 aperture using the median approach and the hanging drop technique, and a pre- prepared 6 ml solution consisting of 80 mg triamcinolone with 10 mg levobupivacaine was injected following standard sterilization. RESULTS: The post-CESI treatment VAS values of the patients were significantly lower than pretreatment VAS values. The treatment success rates for CESI application were 93% in the 1st month, 86% in the 3rd month, and 72% in the 6th month, respectively. CONCLUSION: The CESI application is an effective method in the treatment of cervical radiculopathy and reduces the rate of patients needing surgery.

The comparative effects of transdermal and intramuscular diclofenac on postlaparoscopic surgery pain.

PURPOSE: Postlaparoscopic surgery pain management can reduce the discharge and recovery time. Thus conventional nonsteroidal anti-inflammatory drugs and opioids have been used for this purpose. The aim of this trial was to compare the analgesic and opioid-sparing efficacy of diclofenac sodium intramuscular (IM) with diclofenac transdermal patch in the management of postlaparoscopy pain. METHODS: Patients were randomized to receive IM diclofenac 75 mg (n=30) 15 minutes before anesthesia or transdermal diclofenac (n=30) 3 hours before laparoscopic surgery. Transdermal or IM diclofenac were reapplied 12 hours later. All patients were administered tramadol intravenously before surgery. Postoperative pain management was maintained with tramadol using a patient-controlled analgesia device. Postoperative visual analogue pain scores (VAS, 0 to 10 cm) and adverse reactions were recorded over a 24-hour period. If VAS values were >4, 25 mg tramadol was given intravenously as a rescue analgesic. RESULTS: In both groups, VAS scores were higher in the first 4 hours. There were no significant differences in postoperative pain between the 2 groups. The postoperative tramadol consumption, and rescue analgesic needs of the patients between both groups were not statistically significant. Injection pain was observed in the IM diclofenac group, but for both groups no skin reactions were observed at the application sites of the drugs. CONCLUSIONS: Diclofenac transdermal patch provided pain relief for postoperative laparoscopic surgery as effectively as IM diclofenac and can be used.

Comparison of the analgesic effects of oral tramadol and naproxen sodium on pain relief during IUD insertion.

OBJECTIVE: To compare the analgesic efficacy of oral tramadol and naproxen sodium on pain during insertion of an intrauterine device (IUD). DESIGN: Randomized, double-blinded, clinical trial (Canadian Task Force classification I). SETTING: University-affiliated hospital. Single-center. PATIENTS: One hundred three patients scheduled for insertion of an IUD. INTERVENTIONS: Patients were randomly assigned to receive oral tramadol 50 mg capsules (n = 35) or naproxen sodium 550 mg tablets (n = 34) or placebo (n = 34) 1 hour before insertion of the IUD. After insertion of the IUD, pain intensity was evaluated using a visual analog scale (VAS, 0-10). Adverse effects, patient satisfaction with the medication, and preference for using it during future insertions were also recorded. MEASUREMENTS AND MAIN RESULTS: The VAS scores were significantly different during IUD insertion among the 3 groups (p = .001). Pain scores in the tramadol group were significantly lower than in the naproxen group (p = .003), and the scores in the naproxen group was significantly lower than in the control group (p = .001). Patient satisfaction with the medication and preference for its future use were significantly lower in the control group than in the other 2 groups (p = .001). CONCLUSION: Prophylactic analgesia using 50 mg tramadol and 550 mg naproxen, delivered orally, can be used to relieve pain during IUD insertion. However, tramadol capsules were found to be more effective than naproxen tablets.

Dexmedetomidine for the prevention of shivering during spinal anesthesia.

PURPOSE: The aim of this study was to evaluate the effect of dexmedetomidine on shivering during spinal anesthesia. METHODS: Sixty patients (American Society of Anesthesiologists physical status I or II, aged 18-50 years), scheduled for elective minor surgical operations under spinal anesthesia with hyperbaric bupivacaine, were enrolled. They were administered saline (group C, n = 30) or dexmedetomidine (group D, n = 30). Motor block was assessed using a Modified Bromage Scale. The presence of shivering was assessed by a blinded observer after the completion of subarachnoid drug injection. RESULTS: Hypothermia was observed in 21 patients (70%) in group D and in 20 patients (66.7%) in group C (p = 0.781). Three patients (10%) in group D and 17 patients (56.7%) in group C experienced shivering (p = 0.001). The intensity of shivering was lower in group D than in group C (p = 0.001). Time from baseline to onset of shivering was 10 (5-15) min in group D and 15 (5-45) min in group C (p = 0.207). CONCLUSION: Dexmedetomidine infusion in the perioperative period significantly reduced shivering associated with spinal anesthesia during minor surgical procedures without any major adverse effect during the perioperative period. Therefore, we conclude that dexmedetomidine infusion is an effective drug for preventing shivering and providing sedation in patients during spinal anesthesia.

Use of sonography for rapid identification of esophageal and tracheal intubations in adult patients.

OBJECTIVES: The aim of this study was to investigate the usefulness of sonography for verifying tracheal tube placement within 3 seconds in adult surgical patients. METHODS: This was a blinded prospective randomized study. The anesthesiologist placed the tracheal tube randomly in the trachea (n = 75) or in the esophagus (n = 75) with direct laryngoscopy. A sonographer identified all tracheal and esophageal intubations. The transducer was placed transversely on the neck just superior to the suprasternal notch. The position of the tracheal tube was determined by the sonographer within 3 seconds of tracheal tube placement in the trachea or in the esophagus. RESULTS: We successfully identified 150 correct tracheal tube placements in tracheas and esophagi, resulting in sensitivity of 100% (95% confidence interval, 84%-100%) and specificity of 100% (95% confidence interval, 84%-100%). CONCLUSIONS: This investigation shows that sonography for confirming tracheal intubation is a fast and effective technique.

Evaluation of recovery and anesthetic gas consumption using remifentanil combined with low-flow sevoflurane anesthesia in tympanoplasty.

BACKGROUND: The aim of this study was to compare the effects of low-flow sevoflurane and low-flow sevoflurane supplemented with remifentanil anesthesia on the recovery time, consumption amount of the anesthetic drugs and hemodynamic differences. MATERIALS AND METHODS: A prospective, randomized and double-blinded study with 50 patients was designed. Following intubation, group S received sevoflurane 1.8 vol%, oxygen, nitrous oxide at 4 l · min(-1) and normal saline continuous infusion; group SR received sevoflurane 1.2 vol%, oxygen, nitrous oxide at 4 l · min(-1) and 0.25 µg · kg(-1) · min(-1) remifentanil continuous infusions. Ten minutes after intubation the flow rates decreased to 1 l · min(-1). Consumption of each drug, postoperative recovery characteristics and visual analog scale (VAS) scores for pain were recorded. RESULT: There were no significant differences in hemodynamic parameters, tramadol consumption and VAS scores for pain. The patients in group SR showed faster early recovery as compared to group S. The mean consumption of sevoflurane was 18 ml in group SR, while it was 25 ml in group S. CONCLUSIONS: Low-flow sevoflurane anesthesia combined with remifentanil regimen in patients undergoing tympanoplasty surgery resulted in a faster early recovery and decreased sevoflurane consumption.

A comparison of articaine and fentanyl-supplemented articaine for hemodialysis fistula creation under ultrasound-guided axillary block.

The aim of this prospective randomized, double-blinded study was to evaluate the effect of fentanyl addition to articaine on the duration of sensory as well as motor blocks, and the duration of analgesia during hemodialysis fistula creation under ultrasound-guided axillary block. Fifty patients were randomly allocated to two groups, an articaine group (A), receiving 40 mL of articaine HCI (20 mg/mL) with 2 mL of isotonic sodium chloride solution, and an articaine-fentanyl group (AF), receiving 40 mL of articaine HCI (20 mg/mL) with 2 mL (100 µg) of fentanyl. The onset as well as the duration of sensory and motor blocks, the time necessary for first analgesic administration, the hemodynamic parameters, and the side effects were recorded. Three patients in Group A and two patients in Group AF due to incomplete block were excluded from the study. The duration of sensory and motor blocks was significantly longer in the AF group than in the A group. The first time for analgesic need was also significantly longer in group AF (363 ± 134 min) than in group A (244 ± 84 min) (p = 0.001). The addition of fentanyl did not improve the onset of sensory and motor block times. Hemodynamic parameters were similar in the two groups. In conclusion, the addition of fentanyl to articaine in axillary block prolongs the duration of sensory and motor blocks, as well as the time of first analgesic requirement.

Patient-controlled analgesia and sedation with alfentanyl versus fentanyl for colonoscopy: a randomized double blind study.

STUDY OBJECTIVE: The aim of this study was to evaluate whether sedo-analgesia with alfentanyl/fentanyl, using a patient-controlled analgesia (PCA) pump, may have positive outcomes in terms of safety, postprocedural workload, and expectations of the colonoscopist, nurse, and patients in elective colonoscopy. PATIENTS: One hundred American Society of Anesthesiology physical status I and II adult patients. INTERVENTIONS: Patients were randomized in a double-blind trial to receive either alfentanyl (n=50) or fentanyl (n=50) by PCA, and incremental doses of midazolam. MEASUREMENTS: Patient expectations were assessed using hemodynamic variables, willingness to have a repeat colonoscopy in the same way, adverse events, discomfort scores, and patient/operator/nurse satisfaction associated with sedo-analgesia. RESULT: All patients in both groups had adequate sedo-analgesia with high satisfaction and willingness scores. There were no serious adverse effects and except for a few events, no required medication. The total sedation times were shorter in the alfentanyl group compared with the fentanyl group. CONCLUSIONS: PCA and sedation with alfentanyl and fentanyl for colonoscopy are safe, feasible, and acceptable to most patients. However, shorter sedation times make alfentanyl more attractive for postprocedural workload.