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.

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.

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.

Anaesthetic Management of Children with Rubinstein-Taybi Syndrome.

Rubinstein-Taybi syndrome (RTS) is a rare, autosomal dominant syndrome presenting with mental retardation and physical abnormalities, including broad thumbs, big and broad toes, short stature and craniofacial anomalies. Special attention was paid to the possibilities of difficult airway, aspiration pneumonia and cardiovascular dysfunction during anaesthesia. Micrognathia, retrognathia, broad nasal bridge, abnormally large or 'beak-shaped' nose, hypoplastic maxilla and small mouth-typical dysmorphic facial features are one of the biggest causes of the difficult airway in this syndrome. Approximately one-third of the affected individuals have a variety of congenital heart diseases. Recurrent respiratory infections are likely to be the result of microaspiration or gastro-oesophageal reflux in this syndrome. In this case report, we discussed the anaesthesia management of a child with RTS who underwent right endoscopic dacryocystorhinostomy.

The Anaesthetic Management of a Patient with Maple Syrup Urine Disease.

Maple syrup urine disease (MSUD) is an autosomal recessive metabolic disorder caused by a deficit of oxidative decarboxylation of branched-chain aminoacids. It leads to a build-up of leucine, isoleucine, valine, and toxic metabolites in blood and urine, progressing to acute and chronic brain dysfunction. The first symptoms appear in early childhood and are characterized by sweet-smelling urine, with an odor similar to that of maple syrup. At birth, infants seem healthy, but if untreated, they may suffer from neurological deterioration, seizures, hypertonia, or ataxia. During stressful situations, such as infection or surgery, patients may experience severe ketoacidosis, rapid neurological deterioration, and hypoglycemia. We report the anaesthetic management in a child patient with MSUD, admitted for peritonal dialysis catheter insertion with general anaesthesia.

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.

Histopathologic evaluation of autologous blood injection to the temporomandibular joint.

PURPOSE: Chronic recurrent temporomandibular joint dislocation is treated by surgical and nonsurgical techniques described in the literature. However, these techniques have some complications noted in the literature. Recently, the autologous blood injection in temporomandibular joint technique has been applied to treat chronic temporomandibular joint dislocation. However, to date, there has been no study that describes the histopathologic effects of autologous blood injection within the literature. The aim of this study was to evaluate the histopathologic effects of autologous blood injection in rabbit temporomandibular joints. METHODS: Eight New Zealand white rabbits underwent bilateral autologous blood injection. After the injection, mandibles were fixed by orthodontic brackets and elastics for 24 hours. One rabbit was included in the control group. After 1-month follow-up period, the animals were killed. Temporomandibular joints were dissected and sent to histological examination. RESULTS: Only fibrin accumulations were seen in the tissue samples. There was no evidence of degeneration in the joint cartilage, and a fibrous bed was not formed in the injected regions. CONCLUSIONS: Although the procedure has successful results in the literature, a fibrous bed that is supposed to be the outcome of the treatment was not seen in the tissue samples. According to this study, therefore, the autologous blood injection does not change the structure of temporomandibular joint in rabbits.

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.

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 percent) in group D and in 20 patients (66.7 percent) in group C (p = 0.781). Three patients (10 percent) in group D and 17 patients (56.7 percent) 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.

Magnesium sulfate infusion prevents shivering during transurethral prostatectomy with spinal anesthesia: a randomized, double-blinded, controlled study.

STUDY OBJECTIVE: To determine whether magnesium sulfate (MgSO(4)) infusion during surgery reduces shivering during spinal anesthesia. DESIGN: Double-blinded placebo-controlled, randomized trial. SETTING: Operation room of a university hospital. PATIENTS: 60 patients, aged 40 to 70 years, scheduled for elective transurethral resection of the prostate (TURP) during spinal anesthesia. INTERVENTIONS: Subarachnoid anesthesia consisting of hyperbaric bupivacaine three mL 0.5% was injected using a 25-G Quincke spinal needle. Patients received either saline (Group C, n = 30) or MgSO(4) (Group Mg, n = 30). Group Mg received an intravenous (IV) bolus of MgSO(4) 80 mg/kg via syringe pump over a 30-minute period, followed by a two g/hr infusion during the intraoperative period. Group C received an equal volume of saline. MEASUREMENTS: Motor blockade was evaluated by Bromage motor scale. Sensory block level was assessed by pinprick test. Shivering was assessed after the completion of subarachnoid drug injection. Side effects were recorded. MAIN RESULTS: Hypothermia was observed in all patients (100%) in Group Mg and in 24 patients (80%) in Group C (P = 0.024). The decrease in core temperature in Group Mg was significantly greater (P < 0.005). Shivering was observed in two patients (6.7%) in Group Mg and 20 patients (66.7%) in Group C (P = 0.0001). CONCLUSIONS: MgSO(4) infusion in the perioperative period significantly reduced shivering during TURP with spinal anesthesia. MgSO(4) infusion prevents shivering in patients receiving spinal anesthesia but increases the risk of hypothermia.

Effects of a topical hemostatic agent on an epistaxis model in rabbits.

BACKGROUND: Ankaferd BloodStopper (ABS) is a standardized herbal compound consisting of 5 different plant extracts. ABS, as a topical medicinal product, has been approved by the Turkish Ministry of Health for the management of dermal, external postsurgical and postdental surgery bleedings. OBJECTIVE: The aim of this study was to assess the hemostatic effect of ABS in an experimental epistaxis model. METHODS: Adult female New Zealand rabbits were used in this study. Standardized full-thickness mucosal wounds were created to provide bleeding on the right and left side of the nasal septum of rabbits with a 3-mm surgical punch. To stop bleeding, the wounds were treated with topical ABS on one side and with topical isotonic saline solution as a control on the other side of the nasal septum. Investigators were blinded to treatment. The duration of bleeding was measured in order to compare the hemo-static effect with ABS or topical isotonic saline solution. The wounds were observed for the duration of bleeding in order to compare the hemostatic effect of ABS with isotonic saline solution and acute adverse effects (AEs) for 30 minutes by a researcher blinded to treatment groups. RESULTS: Six rabbits (mean weight, 2.6 kg [range, 2.3-3.1 kg]) were used in this study. Mean (SD) bleeding time in the wounds administered ABS (98 [17] sec) was significantly less than that of the controls (266 [36] sec; P = 0.004). No AEs were observed up to 30 minutes after study initiation. CONCLUSION: This study suggests that ABS may be more effective in reducing time to hemostasis when compared with isotonic saline solution in this epistaxis model in rabbits.