Effectiveness of Peripheral Nerve Block in Terms of Search for a Standardized Treatment Protocol in Diabetic Foot Patients Using Anticoagulants: A Double-Center Study.

BACKGROUND: Lower-extremity amputation for a diabetic foot is mainly performed under general or central neuraxial anesthesia. Ultrasound-guided peripheral nerve block (PNB) can be a good alternative, especially for patients who require continuous anticoagulation treatment and patients with additional comorbidities. We evaluated bleeding due to PNB application in patients with diabetic foot receiving antiplatelet or anticoagulant therapy. Perioperative morbidity and mortality and the need for intensive care hospitalization were analyzed. METHODS: This study included 105 patients with diabetic foot or debridement who underwent distal foot amputation or debridement between February and October 2020. Popliteal nerve block (17 mL of 5% bupivacaine and 3 mL of saline) and saphenous nerve block (5 mL of 2% lidocaine) were applied to the patients. Postoperative pain scores (at 4, 8, 12, and 24 hours) and complications due to PNB were evaluated. Intensive care admission and 1-month mortality were recorded. RESULTS: The most common diseases accompanying diabetes were hypertension and peripheral artery disease. No complications due to PNB were observed. Mean ± SD postoperative first analgesic need was determined to be 14.1 ± 4.1 hours. Except for one patient, this group was followed up without the need for postoperative intensive care. In 16 patients, bleeding occurred as leakage from the surgical area, and it was stopped with repeated pressure dressing. Mean ± SD patient satisfaction score was 8.36 ± 1.59. Perioperative mortality was not observed. CONCLUSIONS: Ultrasound-guided PNB can be an effective and safe anesthetic technique for diabetic patients undergoing distal foot amputation, especially those receiving antiplatelet or anticoagulant therapy and considered high risk.

Investigation of the analgesic effects of rhomboid intercostal and pectoral nerve blocks in breast surgery.

PURPOSE: The objective of this study was to examine the hypothesis that the opioid consumption of patients who receive a rhomboid intercostal block (RIB) or a pectoral nerve (PECS) block after unilateral modified radical mastectomy (MRM) surgery is less than that of patients who receive local anesthetic infiltration. METHODS: Eighty-one female patients aged 18-70 years who underwent unilateral MRM surgery with general anesthesia were randomly allocated to three groups. The first group received an RIB with 30 ml of 0.25% bupivacaine on completion of the surgery, and the second received a PECS block with the same volume and concentration of local anesthetic. In the third (control) group, local infiltration was applied to the wound site with 30 ml of 0.25% bupivacaine at the end of the surgery. The patients' total tramadol consumption, quality of recovery (QoR), postoperative pain scores, and sleep quality were evaluated in the first 24 h postoperatively. RESULTS: Both the RIB (58.3 ± 22.8 mg) and PECS (68.3 ± 21.2 mg) groups had significantly lower tramadol consumption compared to the control group (92.5 ± 25.6 mg) (p < 0.001 and p = 0.002, respectively). Higher QoR scores were observed in the RIB and PECS groups than the control group at 6 h post-surgery. The lowest pain values were observed in the RIB group. The sleep quality of the patients in the RIB and PECS groups was better than that of the control group (p < 0.001). CONCLUSION: Compared to local anesthetic infiltration, the RIB and PECS blocks applied as part of multimodal analgesia in MRM surgery reduced opioid consumption in the first 24 h and improved the quality of recovery in the early period.

Anesthetic approach to trauma patients in the city hospital after the 2023 Maras earthquake.

BACKGROUND: The February 6, 2023, Kahramanmaras earthquake caused significant destruction across our country. More than 50,000 people lost their lives, thousands were injured, and health facilities were damaged. Victims were transferred to hospitals in other provinces for treatment. This study evaluates the anesthesia approach applied to the injured who were transferred to our tertiary hospital. METHODS: We retrospectively reviewed the data of patients who underwent surgery between February 6 and February 20, 2023. The study included earthquake victims who underwent emergency trauma surgery, aged 10 years and above. We recorded the date of admission to the hospital, demographic information, type of surgery, surgical site, anesthesia technique, preference for peripheral block, laboratory values, dialysis and intensive care needs, and survival rates. Data analysis was performed using the IBM® Statistical Package for the Social Sciences (SPSS®) Version 26.0. RESULTS: A total of 375 cases were included in the study. Of these, 323 patients underwent surgery for extremity injuries, and 35 for vertebral injuries. Among the extremity injuries, 61.6% were to the lower extremities, and 17.1% to the upper extremities. Debridement was performed on 147 patients, fasciotomy on 49 patients, and amputation on 33 patients. General anesthesia was applied to 352 patients, spinal anesthesia to 19 patients, and sedoanalgesia to four patients. Peripheral nerve block was performed on 33 patients. Dialysis treatment was administered to 105 patients. Twenty-six patients were lost during the treatment process. There were no intraoperative patient deaths. CONCLUSION: The predominance of extremity injuries among earthquake victims increases the inclination towards regional anesthesia. Incorporating Plan A blocks into basic anesthesia skills could enhance the preference for regional anesthesia in disaster situations. Furthermore, transferring the injured to advanced centers may reduce morbidity.

[Artificial intelligence-powered ultrasound guided regional nerve block in three patients: Case report]. / Yapay zeka destekli ultrasonografi rehberliginde 3 hastada rejyonel sinir bloku: Olgu sunumu.

The use of ultrasound in regional anesthesia plays an important role in determining the variable anatomical structures and their localization. In these days, developments in ultrasonography devices and probes, hardware, and software technologies such as real-time needle tip tracking are increasing rapidly. Artificial intelligence-powered ultrasonography is one of them. In this case report, we aimed to present three cases where regional block was applied using artificial intelligence-powered (Nerveblox) ultrasound. Infraclavicular nerve block to two of our patients and pectoral nerve block to the third one were applied successfully once at a time. None of the patients developed vascular puncture or local anesthetic toxicity. The use of artificial intelligence support in peripheral nerve blocks may reduce the number of attempts and duration of interventions.

Wilson Disease Combined with Keratoconus: A Case Report.

A case of Wilson disease (WD) combined with keratoconus (KC) is described. A 30-year-old male diagnosed with WD presented to Ophthalmology Department due to progressive bilateral vision loss. Biomicroscopy revealed copper depositional ring and mild central corneal ectasia in both eyes. The patient had essential tremors and mild speech disturbance. The keratometric values were K1 = 45.94 diopters (D), K2 = 49.10 D in the right eye, and K1 = 47.14 D, K2 = 51.22 D in the left eye. The maximal elevation points on the posterior elevation maps were 98 mm for the right eye and 94 mm for the left eye. The typical KC pattern was seen on corneal topography bilaterally. Based on these findings, the patient was diagnosed with KC, and corneal cross-linking treatment was recommended. WD rarely occurs in combination with KC, and only two cases have been reported; this is the third case of WD combined with KC so far.

The Role of Oxidative Status in the Pathogenesis of Primary Open-Angle Glaucoma, Pseudoexfolyation Syndrome and Glaucoma.

PURPOSE: To investigate the role of oxidative stress and antioxidant system in the etiopathogenesis of pseudoexfoliation and progression of pseudoexfoliation syndrome to glaucoma. MATERIAL AND METHOD: A total of 20 patients with pseudoexfoliation syndrome, 20 with pseudoexfoliation glaucoma, 20 with primary open-angle glaucoma, and 20 without pseudoexfoliation and glaucoma as a control group, who underwent cataract or glaucoma surgery between December 2020 and March 2021 in the Health Sciences University Beyoglu Eye Training and Research Hospital, 80 patients were included in the study. Best corrected visual acuity (BCVA), intraocular pressure with applanation tonometry, detailed anterior and posterior segment examinations with biomicroscopy were performed in all patients included in the study. Approximately 0.1 cc of anterior chamber fluid was taken from all patients at the beginning of surgery. Total Oxidant Status (TOS) and Total Antioxidant Status (TAS) levels were measured by keeping the samples taken in the deep freezer of the cornea bank at -80 degrees, transferring them with cold chain transport rules, and examining them with automatic measurement method in the laboratories of the Medical Biochemistry Department of the University of Health Sciences. Oxidative Stress Index (OSI) value was calculated to measure the degree of oxidative stress. RESULTS: TAS averages of the control and POAG groups were found to be statistically significantly higher than the PES and PEG groups (p = 0.0001, p = 0.0001). No significant difference was observed between the other groups (p > 0.05). The TOS averages of the control and POAG groups were found to be statistically significantly lower than the PES and PEG groups (p = 0.003, p = 0.0001; p = 0.01, p = 0.001), no statistically significant difference was observed between the other groups (p > 0.05). The OSI mean of the control and POAG groups was found to be statistically significantly lower than the PES and PEG groups (p = 0.001, p = 0.0001; p = 0.002, p = 0.0001), no statistically significant difference was observed between the other groups (p > 0.05). CONCLUSION: Increased TOS and OSI and decreased TAS levels in the aqueous humour of patients with PES and PEG suggest that increased oxidative stress and decreased antioxidative defense system play a role in the etiopathogenesis of the disease.

Analgesic efficacy of ultrasound guided unilateral erector spinae plane block for laparoscopic inguinal hernia repair: a randomized controlled study.

BACKGROUND: Although laparoscopic inguinal herniorrhaphy is associated with faster return to daily activity, inadequate postoperative pain control can cause prolonged hospital stays and patient discomfort. Erector spinae plane block (ESP) can be administered for postoperative pain management in abdominal and thoracic surgery. We investigated the effects of unilateral ESP block application in laparoscopic hernia surgery. METHODS: A total of 60 patients who were scheduled for laparoscopic inguinal hernia surgery were included. ESP block was performed in group E (n = 30) after induction of anesthesia. There was no intervention in Group C (n = 30). Postoperative pain was assessed by the patient using the numeric rating scale (NRS) at postanesthetic care unit (PACU),1, 4, 6, 12, and 24 h after surgery. The quality of postoperative functional recovery was evaluated using the quality of recovery-40 questionnaire. RESULTS: NRS scores were lower in Group E (n = 30) than in Group C (n = 30) at PACU, 1th, 4th, 6th hours in both rest and movement. Total tramadol consumption was reduced at postoperative 24 h by the ESP block [median(IQR), 60(40) versus 85(30)]. Quality of recovery score of the patients after operation was better in the ESP group than in the control group [mean(SD), 177.9(6.5) in group E and 173.2(7.09) in group C with mean differences: 4.633 and CI: 95% (1.11 to 8.15) respectively]. DISCUSSION: Unilateral ESP blocks in laparoscopic inguinal hernia surgery reduce both postoperative pain levels and analgesic consumption. In addition, the ESP block could be used safely in pain management of this type of surgery and improve the quality of recovery.

Anti-fibrotic Treatment for Pulmonary Fibrosis Induced by COVID-19: A Case Presentation.

Coronavirus disease 19 infection clinical presentation varies from asymptomatic cases to acute respiratory distress syndromes. In some cases, pulmonary fibrosis is observed after or during the disease. Pirfenidone is an agent approved for the treatment of idiopathic pulmonary fibrosis. Here we report a patient treated with pirfenidone for pulmonary fibrosis related to coronavirus disease 19.

Is COVID-19 Infection a Trigger for Herpetic Stromal Keratitis?

In June 2020, a 28-year-old female patient was admitted to our clinic with reduced vision in the left eye. She had systemic COVID-19 infection in May 2020 and during her treatment course, her visual complaints had begun approximately 1 week after the beginning of the COVID-19. Previously, the patient had bilateral femtosecond assisted - Laser in situ Keratomileusis in our clinic in 2018. There was no previous history of herpetic eye involvement. In her examination, the uncorrected visual acuity was 20/20 in the right and 20/32 in her left eye. Slit-lamp examination revealed interlamellar infiltration at the flap interface in the left eye. Considering herpetic activation, ganciclovir ointment 5 × 1, valacyclovir tablet 2 × 1, and prednisolone acetate 1.0% eye drops 5 times a day and artificial tear 5 × 1 were started. Two weeks later, the infiltration completely resolved and the uncorrected visual acuity increased to 20/20.

Is HFJV a better alternative ventilation technique for percutaneous dilatational tracheostomy? A randomized trial.

BACKGROUND: High-frequency jet ventilation (HFJV) has been used for the treatment of tracheal lesions, airway surgery, and treatment of secondary lesions after tracheostomy for many years however, reports on the use of HFJV during percutaneous dilatational tracheostomy (PDT) are limited. This study compares the use of traditional method, ventilation with laryngeal mask airway (LMA), and HFJV through endotracheal tube (ETT) with respect to the duration of PDT procedure and complications. METHODS: Seventy-five patients were randomized into one of the three groups with computer-generated random numbers: Group ETT (N.=25), group LMA (N.=25), and group HFJV (n=25). Demographic data, duration of PDT, complications such as ETT cuff puncture and tube transaction, accidental extubation, difficult cannula insertion, bleeding, desaturation during the procedure, arterial blood gases immediately before and after the procedure have been recorded. RESULTS: Mean time for successful PDT in group ETT was 5.9±1.35 minutes, in group LMA 4.96±0.78 minutes, and 3.88±0.78 minutes in group HFJV. PDT duration was shorter in the LMA group than in the ETT group (P<0.05). In the HFJV group, the PDT duration was shorter than the LMA group (P<0.05) and the ETT group (P<0.001). In terms of the total number of complications, significantly fewer complications were observed in the HFJV group compared with group ETT and group LMA. CONCLUSIONS: HFJV may be a more effective alternative method for airway management during PDT, facilitating and reducing the duration of the intervention.

Comparison of the standard and triple airway maneuvering techniques for i-gel™ placement in patients undergoing elective surgery: a randomized controlled study.

PURPOSE: The i-gel is a supraglottic airway device with non-inflatable cuff which can suffer insertion failure if its standard placement technique is implemented. The aim of this study was to compare the placement technique proposed by the manufacturer of i-gel with the triple airway maneuver in terms of successful device insertion time and first-attempt success. METHODS: After ethics committee approval, 103 ASA I-III patients were randomly allocated to the standard or triple airway maneuver groups. In the standard Group, the i-gel was inserted in the sniffing position while, in the triple group, it was inserted using the triple airway maneuver consisting of head tilt, jaw thrust, and open mouth. The time taken for successful insertion, first-attempt success rate, i-gel position, airway complications, and hemodynamic responses were assessed. RESULTS: Between the two groups patient characteristics were similar. Time for successful insertion was significantly shorter in the triple group (20 ± 7 s) than with the standard technique (32 ± 11 s; p < 0.001). Successful insertion at the first attempt was 78% and 92% for the standard and triple group, respectively (p = 0.092). The i-gel position, airway complications, and hemodynamic responses were similar in both groups. CONCLUSION: The triple airway maneuver required less i-gel insertion time as compared with the standard placement technique. First-attempt success rates were similar with both techniques, although the triple airway maneuver was superior to the standard method as a rescue technique in failed insertions. We therefore recommend use of the triple airway maneuver in i-gel insertion.

Effects of suprascapular and axillary nerve block on postoperative pain relief sevoflurane consumption and visual clarity in arthroscopic shoulder surgery.

OBJECTIVES: This study aims to investigate the effects of suprascapular nerve and axillary nerve block on postoperative pain, tramadol consumption, sevoflurane consumption and visual clarity of the surgical field in arthroscopic shoulder surgery. METHODS: Forty-six patients undergoing arthroscopic shoulder surgery were randomized to receive either both suprascapular and axillary nerve block with ultrasound guidance (20 ml 0.25% bupivacaine) before general anesthesia (group SSAXB, n=23) or a subacromial local infiltration (20 ml 0.25% bupivacaine) after the procedure (group control, n=23). End-tidal sevoflurane consumption, visualization of the arthroscopic field scores of the patients were recorded during the procedure. The patient's postoperative pain scores (at PACU, 4, 8, 12, 24 hours after the surgery) and tramadol consumption were also recorded. RESULTS: End-tidal sevoflurane concentration values were similar in both groups (p>0.05). Group SSAXB had a better mean static pain score in the PACU (Group SSAXB 4.27±1.48 vs Group C 6.24±1.09 p<0.05). Tramadol consumption was lower in group SSAXB than in group C (253.1±85.3 mg vs 324.2±72 mg, p=0.005). Visual clarity scores of the arthroscopic field were higher in group SSAXB than in group C along the intraoperative period (p<0.05). CONCLUSION: SSAXB are effective in postoperative analgesia, reduce tramadol consumption and provide a clean image in the arthroscopic area of arthroscopic shoulder surgery, but these blocks do not reduce sevoflurane consumption.

The effects of pregabalin and adductor canal block on postoperative pain in arthroscopic anterior cruciate ligament reconstruction

Background/aim: To determine the effectiveness of pregabalin and adductor canal block on opioid consumption, postoperative pain, and fast-tracking. Materials and methods: A total of 51 American Society of Anaesthesiologists (ASA) classification I­II patients aged 18­70 years who were scheduled to undergo elective anterior cruciate ligament reconstruction were included in the study. Patients were randomized into groups P, A, and C. Patients in group P (n = 16), received 150 mg of preoperative oral pregabalin, patients in group A (n = 17) received postoperative adductor canal blockade, and patients in group C (n = 18) received neither adductor canal block nor pregabalin. Surgeries were performed under spinal anaesthesia with hyperbaric bupivacaine following monitorization. Demographic data along with block features, hemodynamic data, mean opioid consumption, numerical rating scale score, White's fast-track score, and postoperative adverse effects were recorded. Results: Fifty-seven patients were enrolled in the study, and 6 patients were excluded from the study; the data of 51 patients were included in the final analyses. Demographic characteristics and hemodynamic data were similar between the 3groups. Postoperative opioid consumption was significantly lower in groups A and P compared with group C (group P = 178.75 mg, group C = 318.61 mg, group A = 236.47 mg; P < 0.05). The regression of sensory block was significantly slower in group P (P < 0.05). The first analgesic requirement was earlier in group C than in groups P and A (P < 0.05). Patients in group P had higher fast-track scores at 8 h and 12 h compared with group C (P < 0.05); however, group A fast-track scores were similar to those of the other 2groups (P > 0.05). The rate of postoperative adverse effects was similar between the groups (P > 0.05). Conclusion: Preoperative pregabalin (150 mg) reduced postoperative opioid consumption as much as adductor canal block in patients undergoing anterior cruciate ligament reconstruction. The first analgesic requirement was earlier in group C than in groups P and A. In addition, pregabalin can prolong the duration of spinal sensory block and shorten the time required to achieve high fast-tracking scores. We recommend the use of both methods as a part of multimodal analgesia.

The fluorescein angiographic photodiagnosis of idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome: Outcome of combined therapy.

Idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN) syndrome is a disease characterized by multiple retinal macroanurysms, neuroretinitis and ischemia in peripheral vessels, which are difficult to diagnose and cause visual loss if delayed. It consists of 5 stages and causes irreversible vision loss with severe complications after stage 2. In this report, photodiagnosis and combined treatment are defined in a Turkish patient with IRVAN syndrome during 6 months of follow-up. Fundus fluorescein angiography (FFA) showed that bilateral aneurysms in retinal vessels as well as aneurysms and ischemic regions were observed in the inferotemporal retina of the left eye. Argon laser photocoagulation was performed to ischemic regions at the left eye. 2 months later best corrected visual acuities were 20/20 and counting fingers from 1 m in the right and left eyes, respectively. Fundus and OCT images showed that an increase in exudations was observed at the left eye and intravitreal injection of dexametasone implant was considered. Three months after initial presentation, best corrected visual acuities were 20/20 and counting fingers from 2 m in right and left eyes, consequetively. In the last fundus and OCT images, the exudations decreased and disappeared on left eye. In this patient, we could not detect an increase in vision due to damage of photoreceptor cells because of subretinal exudation. In the shed-light of this case, the combination therapy seems to improved the anatomical and functional outcomes in IRVAN syndrome however close follow-up and frequent examinations should be prioritized.

Popliteal block for lower limb surgery in children with cerebral palsy: effect on sevoflurane consumption and postoperative pain (a randomized, double-blinded, controlled trial).

PURPOSE: The aim of this study was to evaluate the effects of a preoperative popliteal block on sevoflurane consumption, postoperative pain, and analgesic consumption in children with cerebral palsy (CP) following lower limb surgery. METHODS: Fifty-four patients undergoing lower limb surgery were randomized to receive either a popliteal block + general anaesthesia (group P, n = 27) or general anaesthesia without a popliteal block (group C, n = 27). After anesthesia induction with 50% N2O, O2, and 8% sevoflurane, a popliteal block was given to group P patients with ultrasound guidance as a single dose of 0.3 ml/kg body weight of 0.25% bupivacaine. Group C patients received the same regimen of anesthesia induction but no preoperative popliteal block. Both the conductance fluctuation (SCF) peak numbers per second and the Wong-Baker FACES® Pain Rating Scale (WBFS) values of the patients were recorded upon arrival at the PACU, at 10 and 20 min after arrival at the PACU, and at postoperative hours 1, 4, 8, 12, and 24 when they were in the ward. The total paracetamol consumption of the patients was also recorded. RESULTS: The end-tidal sevoflurane concentration values were significantly higher in group C patients than in group P patients, except for at 5 min after induction of anaesthesia (p < 0.001). The SCF peak numbers per second and WBFS scores were significantly higher in group C patients than in group P patients, except at Tp24h (p < 0.001). The total paracetamol consumption was 489.7 ± 122.7 mg in group P patients and 816.6 ± 166.5 in group C patients (p < 0.001). CONCLUSION: Popliteal block is effective for postoperative analgesia, decreasing the paracetamol consumption and sevoflurane requirement in children with CP undergoing lower limb surgery. Trial registration ClinicalTrial.gov identifier: NCT02507700.

Caudal Epidural Steroid Injections in Postlaminectomy Patients: Comparison of Ultrasonography and Fluoroscopy.

AIM: To compare the results of ultrasound and fluoroscopy guided caudal epidural steroid injections in postlaminectomy patients. MATERIAL AND METHODS: Thirty postlaminectomy patients were randomly divided into two groups, Group I (n=15) received ultrasound-guided and Group II (n=15) received fluoroscopy-guided caudal epidural local anesthetic and steroid injection. Time of block for each patient was recorded. The patients" visual analogue scale (VAS), Oswestry Disability Index (ODI), and satisfaction with the therapy during the 3-month follow-up were evaluated. RESULTS: The caudal block performed with both methods resulted in similar improvement in low back pain and functions. Time of block was shorter in Group I than in Group II (6.06 ±0.88 minutes versus 11.2±1.14 minutes). CONCLUSION: Caudal epidural steroid injection is an effective analgesic method for postlaminectomy patients. Ultrasound-guided caudal block can be as effective as fluoroscopy-guided block and even more comfortable.

Ultrasound guided chronic pain interventions (Part I).

Recently, ultrasonography (US) is an indispensible imaging technique in regional anesthesia practice. With the guidance of US, various invasive interventions in chronic pain pathologies of the musculoskeletal system, peripheral and neuroaxial pathologies has become possible. The management includes diagnostic blocks as weel as radiofrequency ablation and institution of neurolythic agents. During these algologic interventions we are able to see the target tissue, the dispersion of the drug and all nearby vascular structures. Besides these the US also protects the team from ionic radiation that one encounters when using flouroscopy or computed tomography. Latest publications in this field show that applicability of US in chronic pain syndromes is rapidly expanding with a good future. The additional equipment (echogenic needles, 3-D US etc.) will also expand its applications in algology practice. This review highlights different applications of US in chronic pain conditions.