The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty.

OBJECTIVES: This study aimed to evaluate the effect of preoperative sphenopalatine ganglion block (SPBG) on the postoperative pain (POP) in patients undergoing septorhinoplasty (SRP). METHODS: A retrospective cohort study was performed. A total of 42 patients that had received septorhinoplasty included in the study. The patients that had received SPBG before the surgery included in the Block group (n:20) and the patients that had not received SPBG before the surgery included in the Control group (n:22). POP was questioned with a numeric rating scale (NRS) at the 30th minute (t1), 1st hour (t2), 4th hour (t3), 12th hour (t4), and 24th hour (t5) and noted. The intraoperative details and the dose of the postoperative rescue analgesics were also noted. RESULTS: The average dose of Paracetamol that was used in the postoperative first 24 hours was 500 mg in the Block group and 1363 mg in the Control group, and the difference was statistically significant (P = .001). The average dose of Tramadol was 0 mg in the Block group and 45 mg in the Control group, and the difference was statistically significant (P = .001). There was a statistically significant difference among the groups with respect to NRS in the first 24 hours postoperatively (P < .05). The number of the patients requiring rescue analgesics was lower in the Block group than the Control group. The difference was statistically significant at the t1, t2, and t5 time intervals (P > .05). CONCLUSIONS: Preoperative SPGB is an effective option to reduce POP and the need for rescue analgesics for patients undergoing SRP. CLINICAL TRIAL NUMBER: NCT04020393.

[Our performance of supraclavicular, intercostobrachial and lateral femoral cutaneous block in a patient with high risk undergoing malign melanoma surgery on the forearm]. / Önkolda malign melanom nedeniyle opere edilen yüksek riskli hastada supraklavikular, interkostobrakiyal ve lateral femoral kutanöz blok uygulamasi.

The practice of anesthesia can include the need to accommodate surgical interventions on multiple extremities in a single procedure. General anesthesia is usually preferred in such cases in order to prevent an overdose of local anesthetics. One of the major benefits of using ultrasonography to provide regional anesthesia is that it facilitates reducing the local anesthetic drug dose required to obtain a successful block. The use of multiple, ultrasound-guided extremity blocks can be a reasonable alternative approach to general anesthesia, especially in high-risk patients. This report describes the case of a patient with malignant melanoma of the left lateral forearm. Surgical resection of the lesion, dissection of the axillary sentinel lymph node, and grafting from the lateral left thigh were planned. As the surgical procedure involved more than one extremity, a combination of anesthetic blocks was applied using ultrasound guidance. The use of supraclavicular, intercostobrachial, and lateral femoral cutaneous blocks is explained in the context of the literature.

Comparison of ultrasound-guided transversus abdominis plane block, quadratus lumborum block, and caudal epidural block for perioperative analgesia in pediatric lower abdominal surgery

Background/aim: Despite different regional anesthesia techniques used to provide intraoperative and postoperative analgesia in pediatric patients, the analgesic effectiveness of peripheral nerve blockades with minimal side effect profiles have not yet been fully determined. We aimed to compare the efficacy of ultrasound-guided transversus abdominis plane (TAP) block, quadratus lumborum (QL) block, and caudal epidural block on perioperative analgesia in pediatric patients aged between 6 months and 14 years who underwent elective unilateral lower abdominal wall surgery. Materials and methods: Ninety-four patients classified under the American Society of Anesthesiologists physical status classification system as ASA I or ASA II were randomly divided into 3 equal groups to perform TAP, QL or Caudal epidural block using 0.25% of bupivacaine solution (0.5 ml kg−1). Results: Postoperative analgesic consumption was highest in the TAP block group (P < 0.05). In the QL block group, Pediatric Objective Pain Scale (POAS) scores were statistically significantly lower after 2 and 4 h (P < 0.05). The length of hospital stay was significantly longer in the caudal block group than the QL block group (P < 0.05). Conclusion: We suggest that analgesia with ultrasound-guided QL block should be considered as an option for perioperative analgesia in pediatric patients undergoing lower abdominal surgery if the expertise and equipment are available.

Successful anesthetic management in axillo-axillary bypass surgery.

Axillo-axillary bypass grafting is considered the operation of choice for patients with subclavian steal syndrome. Anesthetic management of high-risk patients with coronary-subclavian steal syndrome presents safety and technical challenges. Presently described is case of chronic obstructive lung disease and coronary artery disease in a 52-year-old man who required axillo-axillary bypass surgery to treat stenosis at the origin of left subclavian artery. Successful anesthetic management was achieved for patient undergoing axillary-axillary bypass surgery using a cervical epidural technique.

Sudden motor and sensorial loss due to retroperitoneal hematoma during postoperative periods: a case report / Súbita perda sensitiva e motora devido a hematoma retroperitoneal durante os períodos de pós-operatório: relato de caso

Abstract A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25 mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

Resumo Paciente do sexo masculino, 68 anos, hospitalizado para prostatectomia radical. O paciente não tinha história médica anormal, inclusive nem déficit neurológico, antes da operação. Antes da anestesia geral, um cateter peridural foi inserido no espaço intermédio L3-4 para analgesia no intra e pós-operatório. Após a cirurgia, que durou nove horas, o paciente desenvolveu confusão e paralisia flácida bilateral dos membros inferiores. Tomografia computadorizada de crânio e imagem de difusão por ressonância magnética não detectaram lesão. Os achados nas imagens de ressonância magnética torácica/lombar eram normais. A pressão intra-abdominal era de 25 mmHg e o ultrassom abdominal revelou progressão de inflamação/edema/hematoma na região perirrenal. O escore de Bromage voltou a 1 no pé direito na 24a hora e no pé esquerdo na 26a hora. A paraplegia desenvolvida nos pacientes após a infusão epidural pode ter sido causada por um efeito potencializado do anestésico local devido a hematoma retroperitoneal e/ou pressão intra-abdominal elevada.

[Sudden motor and sensorial loss due to retroperitoneal hematoma during postoperative periods: a case report]. / Súbita perda sensitiva e motora devido a hematoma retroperitoneal durante os períodos de pós­operatório: relato de caso.

A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

Anesthesia management with ultrasound-guided thoracic paravertebral block for donor nephrectomy: A prospective randomized study.

STUDY OBJECTIVE: To determine the efficacy of ultrasound-guided thoracic paravertebral block intraoperatively and 24 hours postoperatively in patients undergoing donor nephrectomy. DESIGN: Prospective randomized controlled study. SETTING: Private foundation university hospital; November 2014 to June 2015. PATIENTS: Thirty-two patients undergoing donor nephrectomy (exclusion criteria: coagulation disorders, allergy to local anesthetics, and unwillingness to participate). The final study population comprised 30 patients (15 male, 15 female) randomly assigned to either Group P (paravertebral block, n=14) or Group M (morphine, n=16). INTERVENTIONS: In Group P, a unilateral paravertebral catheter was inserted 1 day preoperatively; on the day of surgery, a single-level unilateral paravertebral block was administered through the catheter before general anesthesia. Infusion of bupivacaine continued intraoperatively and postoperatively. Patients in Group M received only general anesthesia, and morphine patient-controlled analgesia was begun postoperatively. MEASUREMENTS: Intraoperative analgesic and anesthetic requirement, postoperative numerical rating scale pain scores, additional analgesic consumption during the postoperative period, and incidence of complications related to thoracic paravertebral block (TPVB) like pleural puncture, pneumothorax, epidural spread, injection into the subarachnoid space, intravascular injection, and Horner's syndrome and rate of opioid related adverse reactions like nausea and vomiting, itching, constipation, and respiratory depression. RESULTS: Intraoperative remifentanil consumption was significantly higher in Group M, and postoperative morphine consumption was significantly lower in Group P (P<.001). During the first 24 hours postoperatively, the mean numerical rating scale pain scores were similar and there were no significant differences between the 2 groups. There were no statistically significant differences in the additional analgesic consumption and rate of adverse reactions between the 2 groups. We didn't detect any complication related to TPVB in group P. CONCLUSIONS: Continuous thoracic paravertebral block provides good intraoperative stability with a low anesthetic requirement and reduces postoperative morphine consumption for up to 24 hours. Ultrasound guided technique enhanced the safety of TPVB and provides analgesia without major complications.

The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting.

STUDY OF OBJECTIVE: To compare the effects of oral tramadol+paracetamol combination on morphine consumption following coronary artery bypass grafting (CABG) in the patient-controlled analgesia (PCA) protocol. DESIGN: A prospective, double-blind, randomized, clinical study. SETTING: Single-institution, tertiary hospital. PATIENTS: Fifty cardiac surgical patients undergoing primary CABG surgery. INTERVENTIONS: After surgery, the patients were allocated to 1 of 2 groups. Both groups received morphine according to the PCA protocol after arrival to the coronary intensive care unit (bolus 1 mg, lockout time 15 minutes). In addition to morphine administration 2 hours before operation and postoperative 2nd, 6th, 12th, 18th, 24th, 30th, 36th, 42th, and 48th hours, group T received tramadol+paracetamol (Zaldiar; 325 mg paracetamol, 37.5 mg tramadol) and group P received placebo. Sedation levels were measured with the Ramsay Sedation Scale, whereas pain was assessed with the Pain Intensity Score during mechanical ventilation and with the Numeric Rating Scale after extubation. If the Numeric Rating Scale score was ≥3 and Pain Intensity Score was ≥3, 0.05 mg/kg morphine was administered additionally. MEASUREMENTS: Preoperative patient characteristics, risk assessment, and intraoperative data were similar between the groups. MAIN RESULTS: Cumulative morphine consumption, number of PCA demand, and boluses were higher in group P (P<.01). The amount of total morphine (in mg) used as a rescue analgesia was also higher in group P (5.06±1.0), compared with group T (2.37±0.52; P<.001). The patients who received rescue doses of morphine were 8 (32%) in group T and 18 (72%) in group P (P<.001). Duration of mechanical ventilation in group P was longer than group T (P<.01). CONCLUSION: Tramadol+paracetamol combination along with PCA morphine improves analgesia and reduces morphine requirement up to 50% after CABG, compared with morphine PCA alone.

Ultrasound guided continuous paravertebral block in a patient with coronary heart disease and sleep apnea syndrome.

The case of a 77-year-old patient with severe coronary heart disease who underwent radical mastectomy with axillary lymph node dissection by ultrasound-guided continuous paravertebral block (CPVB) is described in the present report. Radical mastectomy with axillary dissection is a surgical procedure that necessitates endotracheal intubation and is usually performed under general anesthesia, which carries heightened risk for patients with coronary heart disease (CHD) and sleep apnea syndrome (SAS). Ultrasound-guided CPVB is a simple and safe alternative technique that allows for the use of anesthesia and postoperative analgesia with minimal side effects.

The effect of modified ultrafiltration duration on pulmonary functions and hemodynamics in newborns and infants following arterial switch operation*.

OBJECTIVES: Modified ultrafiltration is used to ameliorate the deleterious effects of cardiopulmonary bypass in pediatric cardiac surgery patients. The ideal duration of modified ultrafiltration has not been established yet. We investigated the effects of extended duration of modified ultrafiltration on pulmonary functions and hemodynamics in the early postoperative period in newborns and infants who had transposition of great arteries operations. DESIGN: Single-center prospective randomized study. SETTING: Pediatric cardiac surgery operating room and ICU. PATIENTS: Sixty newborns and infants who had been scheduled to undergo transposition of great arteries operation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Modified ultrafiltration was applied to all patients following the termination of cardiopulmonary bypass (for 10, 15, and 20 min in groups 1, 2, and 3, respectively). Pulmonary compliance, gas exchange capacity, hemodynamic measurements, inotropic support, blood loss, transfusion requirements, hematocrit level, and duration of ventilatory support were measured after intubation, at termination of cardiopulmonary bypass, at the end of modified ultrafiltration, and in the 1st, 6th, 12th, and 24th hours after admission to ICU. The amount of fluid removed by modified ultrafiltration in groups 2 and 3 was larger than that of group 1 (p < 0.01). Systolic blood pressure was significantly increased at the end of modified ultrafiltration in group 3 compared to groups 1 and 2 (p < 0.05). Hematocrit levels were significantly increased at the end of modified ultrafiltration in groups 2 and 3 compared to group 1 (p < 0.01). Therefore, RBCs were transfused less after modified ultrafiltration in groups 2 and 3 compared to group 1 (p < 0.05). Static and dynamic compliance, oxygen index, and ventilation index had improved similarly in all three groups at the end of modified ultrafiltration (p > 0.05) CONCLUSIONS:: Modified ultrafiltration acutely improved pulmonary compliance and gas exchange in all groups. Increased hematocrit and blood pressure levels were also observed in the longer modified ultrafiltration group. However, extended duration of modified ultrafiltration did not have a significant impact on duration of intubation or the stay in ICU.

The effects of different ventilator modes on cerebral tissue oxygen saturation in patients with bidirectional superior cavopulmonary connection.

AIMS AND OBJECTIVES: We used near-infrared spectroscopy to document changes in cerebral tissue oxygen saturation (SctO2) in response to ventilation mode alterations after bidirectional Glenn (BDG; superior cavopulmonary connection) procedure. We also determined whether spontaneous ventilation have a beneficial effect on hemodynamic status, lactate and SctO2 when compared with other ventilation modes. MATERIALS AND METHODS: 20 consecutive patients undergoing BDG were included. We measured SctO 2 during three ventilator modes (intermittent positive-pressure ventilation [IPPV]; synchronized intermittent mandatory ventilation [SIMV]; and continuous positive airway pressure + pressure support ventilation [CPAP + PSV]). We, also, measured mean airway pressure (AWP), arterial blood gases, lactate and systolic arterial pressures (SAP). RESULTS: There was no change in SctO2 in IPPV and SIMV modes; the SctO2 measured during CPAP + PSV and after extubation increased significantly (60.5 ± 11, 61 ± 10, 65 ± 10, 66 ± 11 respectively) (P < 0.05). The differences in the SAP measured during IPPV and SIMV modes was insignificant; the SAP increased significantly during CPAP + PSV mode and after extubation compared with IPPV and SIMV (109 ± 11, 110 ± 12, 95 ± 17, 99 ± 13 mmHg, respectively) (P < 0.05). Mean AWP did not change during IPPV and SIMV modes, mean AWP decreased significantly during CPAP + PSV mode (14 ± 4, 14 ± 3, 10 ± 1 mmHg, respectively) (P < 0.01). CONCLUSIONS: The SctO2 was higher during CPAP + PSV ventilation and after extubation compared to IPPV and SIMV modes of ventilation. The mean AWP was lower during CPAP + PSV ventilation compared to IPPV and SIMV modes of ventilation.

Anesthesia management with single injection paravertebral block for aorta coarctation in infant.

BACKGROUND: Thoracotomy causes severe pain in the postoperative period. Perioperative thoracic paravertebral block reduces pain score and may improve outcome after pediatric cardiac surgery. This prospective study was designed for the efficacy and duration of a single level, single injection ultrasound-guided thoracic paravertebral block (TPVB) for fifteen infants undergoing aortic coarctation repair. METHODS: After approval of the ethical committee and the relatives of the patients, 15 infants who had undergone thoracotomy were enrolled in the study. The patients received 0.5 ml·kg(-1) a bolus 0.25% bupivacaine with epinephrine 1 : 200 000 at T5-6 level after standard general anesthesia induction. Anesthesia depth with Index of Consciousness (IOC) and tissue oxygen saturation with cerebral (rSO2-C) and somatic thoracodorsal (rSO2-S) were monitored. Intraoperative hemodynamic and postoperative hemodynamic and pain scores were evaluated for 24 h after surgery. Face, Legs, Activity, Cry, Consolability (FLACC) score was utilized to measure postoperative pain in the intensive care unit. Rescue 0.05 mg·kg(-1) IV morphine was applied to patients in whom FLACC was >3. RESULTS: The median age of the patients was 4.5 (1-11) months, and the median intraoperative endtidal isoflurane concentration was 0.6% (0.3-0.8). The amount of remifentanil used intraoperatively was 4.5 (2.5-14) µg·kg(-) (1) ·h(-1). Intraoperative heart rate and blood pressure values significantly decreased compared with values detected at 5th, 10th, and 15th min after TPVB application, after incision prior and after cross-clamp (P < 0.01). The median time of first dose of morphine application after block was 320 (185-430) min. The median morphine consumption in 24 h was 0.16 (0.09-0.4) mg·kg(-1). The median length of postoperative intensive care unit and in-hospital stay times was 23 (1-67) h and 4 (1-10) days, respectively. CONCLUSION: We believe that TPVB, as part of a balanced anesthetic and analgesic regime, provides effective pain relief in patients undergoing aortic coarctation repair.

Thoracic epidural anesthesia and analgesia during the perioperative period of thoracic surgery: levobupivacaine versus bupivacaine.

OBJECTIVES: To compare the effects of thoracic epidural anesthesia with levobupivacaine or bupivacaine on block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery. DESIGN: A prospective, randomized, and double-blind study. SETTING: A university hospital. PARTICIPANTS: Fifty patients undergoing thoracic surgery. INTERVENTIONS: Patients received thoracic epidural catheterization either with levobupivacaine or bupivacaine. A bolus of 0.1 mL/kg of 0.25% levobupivacaine or 0.25% bupivacaine was administered, and infusion of the same drug with 0.25% concentration was started at 0.1 mL/kg/h. General anesthesia was induced after assessing the sensory block and maintained with 0.3% to 0.8% isoflurane and 50% O(2) in air. Epidural patient-controlled analgesia with the same agent was started at the end of the operation for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Sensory block features such as onset time and spread were assessed for the next 20 minutes after the bolus dose. Heart rate and systolic, diastolic, and mean arterial blood pressures were recorded intraoperatively and postoperatively. Pain at rest and activity was evaluated by the visual analog scale (VAS) for 48 hours after the operation. All patients were comparable with respect to the demographic data. Onset time of the block and the number of blocked dermatomes and hemodynamic parameters were similar in both groups. All VAS assessments were comparable between groups except VAS at the 36th hour postoperative, which was higher in the levobupivacaine group (p = 0.039). CONCLUSIONS: Thoracic epidural anesthesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery.