An add-on therapy for neuropathic pain: Infiltration block with diclofenac sodium and lidocaine through the hypertrophic scar tissue.

In some situations, the cause of the supposed neuropathic pain might be related to abnormal tissue recovery such as scar formation due to wound retraction that might create mechanical compression on the nerve tissue. In this report we describe infiltration block with diclofenac sodium and lidocaine through the hypertrophic scar tissue to reduce mechanical stress in 3 patients. The infiltration technique might resolve the tension of the contracted scar tissue by tearing the adhesions and the eliminated mechanical compression would reduce the pressure on nerve tissue and hence neuropathic pain symptoms.

Ketamine dosing for sedation during repeated radiotherapy sessions in children

Background/aim: We report the analysis of ketamine doses needed and the recovery times in pediatric oncology patients undergoing repeated radiotherapy sessions. Materials and methods: In a single-blind prospective study design, thirty-three pediatric patients undergoing radiotherapy due to oncologic disorders received 2 mg/kg ketamine and 10 µg/kg atropine intravenously and the rescue drug to be administered was ketamine at 0.5 mg/kg when the sedation level was inadequate. Total ketamine consumption, additional doses, and recovery time were recorded. Results: Data of 635 consecutive radiotherapy sessions were evaluated. There was no significant alteration in total ketamine consumption required to complete the radiotherapy periods during consecutive procedures (P > 0.05). However, the recovery times started to decrease by the fourth session (P = 0.02) and continued to decrease onwards during the whole study period (P = 0.001). The mean of the first recovery time was 13.68 ± 3.99 min, whereas the mean of the last recovery time was 7.66 ± 6.35 min. Conclusion: A requirement for an incremental increase in ketamine dose after subsequent administrations was not detected, despite a significant decrease in recovery times being anticipated when ketamine is used repeatedly for sedative purposes in consecutive radiotherapy sessions.

Effect of low dose dexmedetomidine premedication on propofol consumption in geriatric end stage renal disease patients.

BACKGROUND AND OBJECTIVE: Sedation in dialysis dependent end-stage renal disease patients requires caution as a result of performing high doses of sedatives and its complications. Multidrug sedation regimens might be superior and advantage on lesser drug consumption and by the way adverse events which occur easily in end-stage renal disease patients. We evaluated the effects of dexmedetomidine premedication on propofol consumption, sedation levels with Observer's Assessment of Alertness and Sedation scores and the bispectral index and the hemodynamic changes, potential side effects in geriatric patients with end-stage renal disease who underwent hip fracture surgery under spinal anesthesia. METHOD: In this randomized, controlled, double-blind study 60 elderly patients (age≥65 years) with end-stage renal disease and hip fracture scheduled for anterograde femoral intramedullary nailing were assigned to groups that received either intravenous saline infusion (Group C) or dexmedetomidine 0.5µg/kg/10min infusion for premedication (Group D). All the patients received propofol infusion after the induction of the spinal anesthesia. RESULTS: Total propofol consumption, propofol dose required for targeted sedation levels according to Observer's Assessment of Alertness and Sedation scores and bispectral index levels, recovery times were significantly lower in Group D (p<0.001). The time to reach to Observer's Assessment of Alertness and Sedation score 4 and to achieve bispectral index≤80 was significantly lower in Group C compared with Group D (p<0.001). Adverse events were similar in both groups. CONCLUSION: Dexmedetomidine premedication lowers intraoperative propofol consumption to maintain targeted level of sedation. Therefore low dose dexmedetomidine premedication in addition to propofol infusion might be an alternative in geriatric patients with end-stage renal disease for sedation.

[Effect of low dose dexmedetomidine premedication on propofol consumption in geriatric end stage renal disease patients]. / Efeito da pré-medicação com dose baixa de dexmedetomidina sobre o consumo de propofol em pacientes geriátricos com doença renal em estágio terminal.

BACKGROUND AND OBJECTIVE: Sedation in dialysis dependent end-stage renal disease patients requires caution as a result of performing high doses of sedatives and its complications. Multidrug sedation regimens might be superior and advantage on lesser drug consumption and by the way adverse events which occur easily in end-stage renal disease patients. We evaluated the effects of dexmedetomidine premedication on propofol consumption, sedation levels with Observer's Assessment of Alertness and Sedation scores and the bispectral index and the hemodynamic changes, potential side effects in geriatric patients with end-stage renal disease who underwent hip fracture surgery under spinal anesthesia. METHOD: In this randomized, controlled, double-blind study 60 elderly patients (age≥65 years) with end-stage renal disease and hip fracture scheduled for anterograde femoral intramedullary nailing were assigned to groups that received either intravenous saline infusion (Group C) or dexmedetomidine 0.5µg/kg/10min infusion for premedication (Group D). All the patients received propofol infusion after the induction of the spinal anesthesia. RESULTS: Total propofol consumption, propofol dose required for targeted sedation levels according to Observer's Assessment of Alertness and Sedation scores and bispectral index levels, recovery times were significantly lower in Group D (p<0.001). The time to reach to Observer's Assessment of Alertness and Sedation score 4 and to achieve bispectral index≤80 was significantly lower in Group C compared with Group D (p<0.001). Adverse events were similar in both groups. CONCLUSION: Dexmedetomidine premedication lowers intraoperative propofol consumption to maintain targeted level of sedation. Therefore low dose dexmedetomidine premedication in addition to propofol infusion might be an alternative in geriatric patients with end-stage renal disease for sedation.

Effect of intraoperative paracetamol on catheter-related bladder discomfort: a prospective, randomized, double-blind study.

BACKGROUND: The insertion of urinary catheters during urinary surgical interventions may lead to catheter-related bladder discomfort (CRBD) in the postoperative period. OBJECTIVE: We aimed to evaluate the effect of single-dose intravenous paracetamol on CRBD. METHODS: In this randomized, controlled, double-blind study, 64 patients (age >18 years, American Society of Anesthesiologists Physical Status I-II) requiring urinary bladder catheterization for percutaneous nephrolithotomy were assigned to groups that received either intravenous paracetamol (15 mg/kg) (group P) or NaCl 0.9% solution (control group [group C]) 30 minutes before the end of surgery. Patients received patient-controlled analgesia (10-mg bolus of meperidine, without infusion, 20-minute lock out) postoperatively. CRBD and pain status were assessed at 30 minutes and 1, 2, 4, 6, and 12 hours postoperatively. Postoperative meperidine requirement and patient and surgeon satisfaction were assessed. RESULTS: Group P had significantly lower CRBD scores at all time points except at 12 hours postoperatively compared with group C (P < 0.05). Total meperidine consumption was significantly higher in group C (P < 0.05). Patient and surgeon satisfaction scores were significantly higher in group P (P < 0.05). CONCLUSIONS: Intraoperative single-dose paracetamol was found to be effective in reducing the severity of CRBD and pain in urologic surgery. We suggest that it may be an efficient, reliable, easy-to-apply drug for CRBD. ClinicalTrials.gov identifier: NCT01652183.

[Modified van-Lint technique for the management of postherpetic neuralgia: case report]. / Post-herpetik nevralji tedavisinde modifiye van-Lint blokaji: Olgu sunumu.

Acute herpes zoster (AHZ) causes postherpetic neuralgia (PHN) in 48-75% of patients. Nerve blocks performed in the acute phase of HZ may treat the pain and prevent PHN development. Here, we present pain relief with modified van-Lint block in two cases with AHZ involving vesicles on the traces of the supraorbital and supratrochlear nerves. Two female patients, 72 and 66 years old, with AHZ involving vesicles on the traces of the supraorbital and supratrochlear nerves starting from the right periocular region to the scalp presented with symptoms such as hypoesthesia, dizziness, burning, throbbing, and severe pain. Their initial visual analogue scale (VAS) scores for pain were 9 and 10, respectively. Supraorbital and supratrochlear nerve blockade with modified van-Lint technique was planned, as the classical nerve block sites were covered with active vesicles. Following the nerve blocks, VAS scores of both patients decreased to 1 immediately. Vesicles were faded and scabbed, symptoms such as hypoesthesia, burning and throbbing had recovered, dizziness was relieved, and VAS scores were 4 and 5, respectively, after one week. VAS scores were 1 and 2, respectively, after the second injection, and all symptoms were resolved, and no additional analgesic was required during a three-month follow-up. Modified van-Lint block with 5 mL 1% lidocaine may provide successful pain relief in AHZ involving vesicles on the traces of the supraorbital and supratrochlear nerves.

Children on phenobarbital monotherapy requires more sedatives during MRI.

BACKGROUND: Phenobarbital induces specific hepatic cytochrome P-450 enzyme pathways causing increased clearance of hepatically metabolized drugs. In this study, we investigated the duration and additional anesthetic requirement during Magnetic resonance imaging (MRI) in epileptic children with or without phenobarbital monotherapy. METHODS: In ASA I-II, 128 children, aged 1-10 years, were included. Group I: epileptic children without anti-epileptic therapy and Group II: children with phenobarbital monotherapy. The initial sedative drugs were 0.1 mg·kg(-1) midazolam with 2 mg·kg(-1) ketamine. An additional 1 mg·kg(-1) ketamine was administrated if required. Rescue propofol (0.5 mg·kg(-1)) was provided and repeated to maintain sedation. The duration and consumption of additional sedative requirements was recorded. RESULTS: The duration of initial and two consequent additional sedative requirements was shorter in Group II (P = 0.0001, P = 0.001 and P = 0.27, respectively). Additional ketamine doses required for adequate sedation were lower in Group I (P = 0.016). CONCLUSION: We suggest that the variability in response to the initial sedative agents during MRI requires titration of additive sedation with ketamine in epileptic children on phenobarbital monotherapy.

Intravenous patient-controlled analgesia using remifentanil in a child with Axenfeld-Rieger syndrome.

Patient-controlled analgesia (PCA) using intravenous opioids is increasing in popularity for children aged 5 years and over. To our knowledge there are no reports on the use of PCA in children with remifentanil in the postoperative period. We report successful use of remifentanil for intravenous (IV) PCA in a child scheduled for suprasellar arachnoid cystectomy with Axenfeld-Rieger syndrome who needed good postoperative analgesia because of accompanying serious problems.

Comparison of hemodynamics, recovery profile, and early postoperative pain control and costs of remifentanil versus alfentanil-based total intravenous anesthesia (TIVA).

STUDY OBJECTIVE: To compare hemodynamics, recovery profiles, early postoperative pain control and costs of total intravenous anesthesia (TIVA) with propofol and remifentanil and propofol and alfentanil. DESIGN: Randomized, double-blind study. SETTING: University hospital. PATIENTS: 40 ASA physical status I and II adult patients scheduled for lumbar discectomy. INTERVENTIONS: Patients were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 1 microg kg(-1) or alfentanil 20 microg kg(-1) with propofol 2 mg kg(-1), and maintained with infusions of propofol 150 to 100 microg kg(-1)min(-1) and either remifentanil 0.1 microg kg(-1) min(-1) or alfentanil 0.5 microg kg(-1) min(-1). MEASUREMENTS: Hemodynamic parameters (heart rate and mean arterial pressure), times to awakening, and tracheal extubation were recorded. In the postanesthesia care unit, pain level, frequency of analgesic demand, frequency of postoperative nausea and vomiting (PONV), partial oxygen saturation (SpO2), and respiratory rates were noted. Drug dosages and costs of each technique were determined. MAIN RESULTS: The mean arterial pressure significantly decreased compared to baseline values 1 minute after induction (p < 0.05) in both groups, and it significantly decreased at 5, 15, and 30 minutes perioperatively in the remifentanil group compared to the alfentanil group (p < 0.05). Time of extubation, spontaneous eye opening, and response to verbal command were similar in both groups. Visual analog scale pain scores at 30 minutes and 60 minutes were significantly lower in the alfentanil group than remifentanil group (p < 0.05). At 15, 30, and 60 minutes after terminating the operation oxygen saturation and respiratory rate were significantly higher (p < 0.05) and analgesics were required sooner in the remifentanil group than the alfentanil group (p < 0.05). The frequency of PONV was similar in both groups. The remifentanil-propofol anesthesia was found to be slightly more expensive as compared to the alfentanil based TIVA (33.41 +/- 4.53 vs. 29.97 +/- 4.1 USD) (p < 0.05). CONCLUSIONS: Both remifentanil and alfentanil provided a reasonably rapid and reliable recovery. The remifentanil-based TIVA was associated with high intraoperative cost and early postoperative pain, but it allowed a more rapid respiratory recovery.