Severe hypokalemia and rebound hyperkalemia during barbiturate coma in patients with severe traumatic brain injury / Hipopotasemia grave e hiperpotasemia de rebote durante el coma terapéutico inducido por barbitúricos en pacientes con lesiones cerebrales traumáticas

OBJECTIVES: To evaluate the incidence of severe potassium disturbances during barbiturate coma therapy in patients with severe traumatic brain injury (TBI), and the characteristics of these patients. METHODS: The study comprised 37 patients with severe TBI who were treated for barbiturate coma between 2015 and 2017 in level 3 intensive care units of two hospitals. RESULTS: No potassium disturbance occurred in 14 patients. Seventeen patients developed mild-moderate hypokalemia (2.6-3.5 mEq/L), and 6 patients developed severe hypokalemia (< 2.5 mEq/L) following the induction of barbiturate therapy. The incidence of mild-to-severe barbiturate-induced hypokalemia was 62.2% and the rate of severe hypokalemia was 16.2%. The mean potassium supply per day during thiopentone therapy was statistically significantly different between patients with mild-to-moderate hypokalemic and those with severe hypokalemic (p < 0.001). Four of 6 patients with severe hypokalemia developed rebound hyperkalemia exceeding 6mEq/L following the cessation of barbiturate infusion. The nadir potassium concentration was 1.5 mEq/L and the highest value was 6.8 mEq/L. The mean time to reach nadir potassium concentrations was 2.8 days. The mortality rate of the 6 patients was 66.7%. Of the 2 survivors of severe hypokalemia, the Glasgow Outcome Scale (GOS) on discharge and the extended GOS one year after the trauma were 5 and 8 respectively. CONCLUSIONS: Severe hypokalemia refractory to medical treatment and rebound hyperkalemia is a serious adverse effect of thiopentone coma therapy in patients with severe TBI. Excessive and aggressive potassium replacement during the barbiturate-induced hypokalemia period must be avoided. Weaning barbiturate treatment over time may be advantageous in the management of severe serum potassium disturbances

OBJETIVOS: Evaluar la incidencia de alteraciones graves de los niveles de potasio durante el coma terapéutico inducido por barbitúricos en pacientes con lesiones cerebrales traumáticas (LCT) graves y las características de estos pacientes. MÉTODOS: El estudio incluyó 37 pacientes con LCT grave que habían sido tratados mediante coma terapéutico inducido por barbitúricos entre 2015 y 2017 en unidades de cuidados intensivos de nivel 3 de dos hospitales. RESULTADOS: En 14 pacientes no se observaron alteraciones de los niveles de potasio. Diecisiete pacientes desarrollaron hipopotasemia leve o moderada (2,6-3,5 mEq/l), y 6 pacientes desarrollaron hipopotasemia grave (< 2,5 mEq/l) después de la inducción de la terapia con barbitúricos. La incidencia de hipopotasemia de leve a grave inducida por barbitúricos fue del 62,2% y la tasa de hipopotasemia grave fue del 16,2%. El aporte medio de potasio al día durante el tratamiento con tiopentona fue diferente de forma estadísticamente significativa entre los pacientes con hipopotasemia leve o moderada y entre los que tenían hipopotasemia grave (p < 0,001). Cuatro de los 6 pacientes con hipopotasemia grave desarrollaron hiperpotasemia de rebote que superó los 6 mEq/l después de la suspensión de la infusión de barbitúricos. La concentración mínima de potasio fue de 1,5 mEq/l y el valor máximo de potasio fue de 6,8 mEq/l. El tiempo medio hasta alcanzar las concentraciones mínimas de potasio fue de 2,8 días. La tasa de mortalidad de los 6 pacientes fue del 66,7%. En los 2 supervivientes con hipopotasemia grave, los resultados de la Escala de Resultados de Glasgow (Glasgow Outcome Scale, GOS) en el alta y la GOS extendida un año después del traumatismo fueron 5 y 8, respectivamente

Severe hypokalemia and rebound hyperkalemia during barbiturate coma in patients with severe traumatic brain injury.

OBJECTIVES: To evaluate the incidence of severe potassium disturbances during barbiturate coma therapy in patients with severe traumatic brain injury (TBI), and the characteristics of these patients. METHODS: The study comprised 37 patients with severe TBI who were treated for barbiturate coma between 2015 and 2017 in level 3 intensive care units of two hospitals. RESULTS: No potassium disturbance occurred in 14 patients. Seventeen patients developed mild-moderate hypokalemia (2.6-3.5mEq/L), and 6 patients developed severe hypokalemia (<2.5mEq/L) following the induction of barbiturate therapy. The incidence of mild-to-severe barbiturate-induced hypokalemia was 62.2% and the rate of severe hypokalemia was 16.2%. The mean potassium supply per day during thiopentone therapy was statistically significantly different between patients with mild-to-moderate hypokalemic and those with severe hypokalemic (p<0.001). Four of 6 patients with severe hypokalemia developed rebound hyperkalemia exceeding 6mEq/L following the cessation of barbiturate infusion. The nadir potassium concentration was 1.5mEq/L and the highest value was 6.8mEq/L. The mean time to reach nadir potassium concentrations was 2.8 days. The mortality rate of the 6 patients was 66.7%. Of the 2 survivors of severe hypokalemia, the Glasgow Outcome Scale (GOS) on discharge and the extended GOS one year after the trauma were 5 and 8 respectively. CONCLUSIONS: Severe hypokalemia refractory to medical treatment and rebound hyperkalemia is a serious adverse effect of thiopentone coma therapy in patients with severe TBI. Excessive and aggressive potassium replacement during the barbiturate-induced hypokalemia period must be avoided. Weaning barbiturate treatment over time may be advantageous in the management of severe serum potassium disturbances.

Intraoperative superior hypogastric plexus block during cesarean section: a new technique for pain relief.

Background: With increasing cesarean section rates all around the world, postoperative pain management is an important issue for all women. Good postoperative pain management helps to shorten the recovery period of the mother, improve the mother's feeling of well-being, enable good breastfeeding, and provide optimum maternal-neonatal bonding.Objective: To evaluate the efficacy of intraoperative superior hypogastric plexus block (SHPB) during cesarean section and describe the technique.Study design: This was a prospective quasi-experimental study that was conducted with 69 pregnant women at HSU. Kocaeli Derince Training and Research Hospital Obstetrics and Gynecology Clinics between 15 March 2018 and 15 August 2018. The case group included 34 healthy pregnant women who received SHPB (SHPB+) for postoperative pain relief during cesarean section under general anesthesia, and the control group included 35 healthy pregnant women who did not receive SHPB during cesarean section with general anesthesia (SHPB-). Postoperative 1st hour, 6th hour, 12th hour, 24th hour, and 48th hour visual analog scale (VAS) scores, the amount of analgesics used for pain relief, and the time of the postoperative first gas extraction were assessed.Results: The SHPB (+) group had lower 1st hour VAS scores than the SHPB (-) group (p < .001). The mean postoperative 1st hour VAS score of the SHPB (+) group was 4.74 ± 1.44, and was 6.80 ± 2.08 for the SHPB (-) group. There were no differences in postoperative 6th hour, 12th hour, 24th hour, and 48th hour VAS scores between the groups. When the SHPB (+) and SHPB (-) groups were compared for postoperative analgesic use and for the first postoperative gas extraction time, the SHPB (+) group had lower analgesic use (p < .001), and the SHPB (-) group had earlier gas extraction. The mean analgesic use in the SHPB (+) group was 2.29 ± 1.11 and it was 4 ± 0.84 in SHPB (-) group. The mean gas extraction time for the SHPB (-) group was 18.03 ± 7.2 h, and was 24.56 ± 8.56 h for the SHPB (+) group (p = .001).Conclusion: SHPB performed intraoperatively in cesarean section procedures with general anesthesia is a simple, easy approach to perform during open surgery with direct vision. SHPB helps postoperative pain management extensively with low postoperative VAS scores and low analgesic requirement.

Can Propofol Lead to an Increase in Seizure Threshold Over the Course of Electroconvulsive Therapy?

OBJECTIVE: To evaluate the effects of 2 different dose regimens of propofol (low dose: < 1 mg/kg, high dose: ≥ 1 mg/kg) on the duration of the seizures, the required energy for the seizures, and the seizure threshold over the course of electroconvulsive therapy (ECT). METHODS: The electronic medical records of 165 patients receiving 971 sessions of ECT were analyzed retrospectively. Patients were evaluated in two groups according to the according to propofol doses that they had received for ECT. Group LP (n = 91): patients who received low dose propofol (< 1 mg/kg). Group HP (n = 74): patients who received high dose propofol (≥ 1 mg/kg). RESULTS: The required energy for seizures in Group HP were significantly higher than the Group LP in the 3rd, 4th, 5th, 6th, 7th, 8th, and 9th sessions (p < 0.05). The duration of seizures in the Group HP were significantly lower than the Group LP in the 1st, 2nd, 4th, 5th, 7th, and 8th sessions (p < 0.05). Higher electrical stimulus was needed to acquire a minimum length of seizure (> 25 sn) during the course of ECT in higher propofol doses. Although there was an increase in the seizure threshold over the course of ECT in both groups, this increase was found to be much more pronounced in the high-dose propofol group according to the low-dose propofol group. Longer duration of seizures was observed in the low-dose propofol group. CONCLUSION: Higher doses of propofol in induction of anesthesia can lead to a more progressive rise in seizure threshold than lower doses of propofol.

Selective Spinal Nerve Block in Ilioinguinal, Iliohypogastric and Genitofemoral Neuralgia.

AIM: To seek the efficacy of selective spinal nerve blocks in the treatment of groin pain that are irresponsive to peripheral nerve blocks. MATERIAL AND METHODS: This retrospective study comprised 17 patients with ilioinguinal, iliohypogastric, and genitofemoral neuralgias treated between 2017 and 2018. RESULTS: All patients received diagnostic peripheral nerve blocks and/or TAP blocks with blind or ultrasound-guided techniques. Four patients had ineffectual peripheral nerve blocks, after which they underwent T12 and L1 selective spinal nerve blocks. All four patients had satisfactory results. CONCLUSION: If distal peripheral nerve blocks are ineffective, an upper level nerve lesion, a lesion in the lumbar plexus or an L1 radiculopathy should be considered in ilioinguinal, iliohypogastric, and genitofemoral neuralgias. Upper level nerve blocks should be performed before deciding on surgery.

Long-term follow-up of tonsillectomy efficacy in children with PFAPA syndrome / Acompanhamento em longo prazo da eficácia da tonsilectomia em crianças com síndrome de PFAPA

Abstract Introduction: The role of tonsillectomy in the periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, is controversial. Although some studies reported high success rates with tonsillectomy, further investigations are needed with larger numbers of patients. Objective: To seek the long-term outcomes of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. Methods: Case series; multi-center study. The study comprised 23 patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome who underwent surgery (tonsillectomy with or without adenoidectomy) between January 2009 and November 2014. Results: 21 (91%) of 23 patients had complete resolution immediately after surgery. One patient had an attack 24 h after surgery, but has had no further attacks. One patient had three attacks with various intervals, and complete remission was observed after 3 months. Conclusions: Tonsillectomy is a good option for the treatment of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome.

Resumo Introdução: O papel da tonsilectomia na síndrome da febre periódica, estomatite aftosa, faringite e adenite é controverso. Embora alguns estudos tenham relatado altas taxas de sucesso com a tonsilectomia, são necessárias mais pesquisas com um número maior de pacientes. Objetivo: Avaliar os resultados em longo prazo da tonsilectomia na síndrome de febre periódica, estomatite aftosa, faringite e adenite. Método: Série de casos; estudo multicêntrico. O estudo avaliou 23 pacientes com síndrome de febre periódica, estomatite aftosa, faringite e adenite submetidos a cirurgia (tonsilectomia com ou sem adenoidectomia) entre janeiro de 2009 e novembro de 2014. Resultados: Dos 23 pacientes, 21 (91%) apresentaram resolução completa imediatamente após a cirurgia. Um paciente apresentou um episódio 24 horas após a cirurgia, mas sem recorrência posterior. Um paciente teve três episódios com vários intervalos e a remissão completa foi observada após 3 meses. Conclusões: A tonsilectomia é uma boa opção para o tratamento da síndrome de febre periódica, estomatite aftosa, faringite e adenite.

Tranexamic acid is effective in lower doses with infusion in total knee arthroplasty.

OBJECTIVE: To identify the most effective intravenous regimen with reduced doses of tranexamic acid (TXA). METHODS: We retrospectively evaluated the two most frequently used TXA regimens (infusion and divided-dose regimens) in total knee arthroplasty in comparison with patients not treated with TXA, in three groups. Group NO (n = 134; 19 men and 115 women; mean age: 66.48 ± 7.66) (patients who were not treated with TXA); group DIV (n = 158; 14 men and 144 women; mean age: 65.67 ± 7.98) (total dose of 10 mg/kg intravenous TXA divided into two doses: 15 minutes before tourniquet inflation and 15 minutes before tourniquet deflation), an extra 5 mg/kg intravenous TXA dose was administered 2 hours after surgery in the orthopedic ward, if needed; and group INF (n = 193; 33 men and 160 women; mean age: 67.08 ± 7.2) (10 mg/kg TXA perioperative intravenous infusion starting 15 minutes before surgery until closure of the wound, and 5 mg/kg additional intravenous dose was administered 12 hours after surgery). Pre-postoperative hemoglobin (Hb) and hematocrit (Htc) difference, total blood loss (TBL), number of transfused packed red blood cells (pRBC), and length of hospital stays (LOS) were compared between the groups. RESULTS: TBL was lower in group INF (531.61 ± 316.76 mL) in comparison with group DIV (999.91 ± 352.62 mL). TBL was statistically significantly higher in Group NO (1139.23 ± 43 mL). The mean number of transfused pRBC was significantly higher in the control group (1.22 ± 0.58 units) than the in the other TXA groups. The mean number of transfused pRBC was significantly lower in INF group (0.33 ± 0.56 units) than DIV group (0.75 ± 0.63 units). The number of patients requiring transfusion was significantly lower in INF group (28.5%) than DIV group (65.2%). Group NO had the highest number of patients requiring transfusion (96.3%). Pre-postoperative Hb and Htc difference was significantly lower in INF group (-1.19 ± 0.9 gr/dL and -3.74 ± 2.96%). The mean LOS of the control group, group DIV and group INF were 7.16 ± 2.29, 6.93 ± 2.39 and 5.06 ± 1.24 days, respectively. Group INF had the lowest hospital stay time in comparison with the other groups (p < 0.005). There was no statistically significant difference between the control group and group DIV in the LOS. CONCLUSION: A total dose of 10 mg/kg of TXA perioperative intravenous infusion starting 15 minutes before the surgery until wound closure can significantly decrease TBL. Intraoperative infusion regimen is more effective than the divided-dose regimen. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Long-term follow-up of tonsillectomy efficacy in children with PFAPA syndrome.

INTRODUCTION: The role of tonsillectomy in the periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, is controversial. Although some studies reported high success rates with tonsillectomy, further investigations are needed with larger numbers of patients. OBJECTIVE: To seek the long-term outcomes of tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome. METHODS: Case series; multi-center study. The study comprised 23 patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome who underwent surgery (tonsillectomy with or without adenoidectomy) between January 2009 and November 2014. RESULTS: 21 (91%) of 23 patients had complete resolution immediately after surgery. One patient had an attack 24h after surgery, but has had no further attacks. One patient had three attacks with various intervals, and complete remission was observed after 3 months. CONCLUSIONS: Tonsillectomy is a good option for the treatment of periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome.

Laparoscopic Superior Hypogastric Blocks for Postoperative Pain Management in Hysterectomies: A New Technique for Superior Hypogastric Blocks.

STUDY OBJECTIVE: To evaluate the effect of intraoperative superior hypogastric blocks on postoperative pain management. DESIGN: Prospective observational cohort study (Canadian Task Force classification II-2). SETTING: Kocaeli Derince Training and Research Hospital, University of Health Sciences, Department of Anesthesiology and Reanimation, Department of Gynecology and Obstetrics, Kocaeli, Turkey. PATIENTS: Sixty female patients who underwent elective laparoscopic hysterectomy were included in this study. Patients were divided into 2 groups: those who had intraoperative superior hypogastric plexus (SHP) block (Hypo; n = 30) and those who did not have intraoperative SHP block (No-Hypo; n = 30). INTERVENTIONS: Intraoperative SHP blocks were performed with the modified laparoscopic technique previously described by us. MEASUREMENTS AND MAIN RESULTS: Rescue analgesic time was calculated in minutes as the time interval between the last administration of analgesic in the operating room or postanesthesia care unit and the first analgesic demand in the surgical ward. Rescue analgesic times were found to be significantly higher in the Hypo group. Nonsteroidal anti-inflammatory drugs and opioid requirements in the postanesthesia care unit and in the surgical ward were significantly lower in the Hypo group. There was no difference between groups in postoperative nausea and vomiting. CONCLUSIONS: Intraoperative SHP block is a preferable modality for postoperative analgesia in patients undergoing hysterectomy. The surgical laparoscopic modified anterior approach we describe is an uncomplicated and easily applicable method. More effective results would be seen if used together with wound site local anesthetic infiltration or abdominal wall plane blocks. (Clinical trial registration no. NCT03427840.).

Unilateral Hypoglossal Nerve Palsy After Septoplasty Under General Anaesthesia.

Hypoglossal nerve palsy (HNP) is a rare perioperative complication. Causes of this condition are mostly attributed to oropharyngeal manipulation during airway management, suggesting injuries involving the peripheral part of the nerve. Owing to the concomitant pathways of the nerves, the hypoglossal nerve might be injured together with the recurrent laryngeal (Tapia's syndrome) or lingual nerves. The present report described a case of isolated HNP as a rare perioperative complication.