Comparison of Intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery.

The aim of our study was to compare bilateral erector spinae plane block (ESPB) efficacy on pain management with patient controlled analgesia (PCA) during the perioperative period in patients scheduled for coronary artery bypass grafting (CABG). After ethics committee approval (2019-7/31 dated 09.04.2019) from the Bursa Uludag University Medical Trials Ethics Committee, (https://uludag.edu.tr/buuetikkurulu) ASA II-III, 50 patients aged between 18-80 years were included. They were randomly divided into two groups, ESPB (n=25) and control (n=25). In the preoperative period, bilateral ESPB with ultrasonography was applied to both groups with 0.25% bupivacaine (0.5 ml/kg) + dexamethasone (8 mg) or saline, respectively. PCA prepared with morphine was given to all patients postoperatively. Perioperative opioid use, extubation times, coughing/resting Visual Analog Scale (VAS) scores, duration for first PCA bolus dose requirement, rescue analgesia needs, mobilization times, and opioid side effects were evaluated. In the ESPB group, compared to the control group, intraoperative fentanyl consumption was lower (P=0.001). During the postoperative period; extubation time was shorter, the need for initial PCA was much later, morphine consumption and need for rescue analgesia was less (P=0.001; P<0.001; P<0.001; P=0.009, respectively). The postoperative VAS scores were lower for each measurement period (P<0.05). Opioid-related side effects were more common in the control group (P=0.040). First mobilization time in ESPB group was earlier (P<0.001). As a result, ESPB has a significant analgesic effect in CABG patients. It was concluded that bilateral ESPB reduces opioid requirement compared to intravenous morphine PCA alone and provides better pain management and more comfortable recovery.

Induction of anesthesia in coronary artery bypass graft surgery: the hemodynamic and analgesic effects of ketamine.

OBJECTIVE: The aim of this prospective, randomized study was to evaluate the hemodynamic and analgesic effects of ketamine by comparing it with propofol starting at the induction of anesthesia until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery. INTRODUCTION: Anesthetic induction and maintenance may induce myocardial ischemia in patients with coronary artery disease. A primary goal in the anesthesia of patients undergoing coronary artery bypass grafting surgery is both the attenuation of sympathetic responses to noxious stimuli and the prevention of hypotension. METHODS: Thirty patients undergoing coronary artery bypass grafting surgery were randomized to receive either ketamine 2 mg.kg(-1) (Group K) or propofol 0.5 mg.kg(-1) (Group P) during induction of anesthesia. Patients also received standardized doses of midazolam, fentanyl, and rocuronium in the induction sequence. The duration of anesthesia from induction to skin incision and sternotomy, as well as the supplemental doses of fentanyl and sevoflurane, were recorded. Heart rate, mean arterial pressure, central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, systemic and pulmonary vascular resistance indices, stroke work index, and left and right ventricular stroke work indices were obtained before induction of anesthesia; one minute after induction; one, three, five, and ten minutes after intubation; one minute after skin incision; and at one minute after sternotomy. RESULTS: There were significant changes in the measured and calculated hemodynamic variables when compared to their values before induction. One minute after induction, mean arterial pressure and the systemic vascular resistance index decreased significantly in group P (p<0.01). CONCLUSION: There were no differences between groups in the consumption of sevoflurane or in the use of additional fentanyl. The combination of ketamine, midazolam, and fentanyl for the induction of anesthesia provided better hemodynamic stability during induction and until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery.

Preoperative multiple-injection thoracic paravertebral blocks reduce postoperative pain and analgesic requirements after video-assisted thoracic surgery.

OBJECTIVE: The hypothesis was tested that preoperative multiple-injection thoracic paravertebral blocks reduce opioid requirements and promote early ambulation after video-assisted thoracic surgery procedures. DESIGN: Prospective, randomized, controlled, blinded study. SETTING: Single-university hospital. PARTICIPANTS: Fifty consenting patients undergoing video-assisted thoracic surgery. INTERVENTIONS: Patients were randomly assigned to receive preoperative multiple-injection thoracic paravertebral blocks (PVB group, n = 25) or preoperative multiple subcutaneous saline injections at the same site as in the PVB group (control group, n = 25). MEASUREMENTS AND MAIN RESULTS: Intraoperative fentanyl consumption was lower in the PVB group (p < 0.01). The time to first analgesic requirement was longer, and pain score at this time was lower in the PVB group (p < 0.05 and p < 0.01, respectively). Postoperative pain scores both at rest and coughing were lower during the first 4 hours in the PVB group than those in the control group (p < 0.01 for 0 hours and p < 0.05 for 1, 2, and 4 hours). Cumulative morphine consumption was significantly less in the PVB group at all time points (p < 0.05 for 12 hours and p < 0.01 for all other time points), but there were no significant differences in sedation scores between the 2 groups. There were no complications because of the blocks. Patient satisfaction with the analgesia was significantly greater (p < 0.05), and first mobilization and hospital discharge were quicker (p < 0.01 and p < 0.05, respectively) in the PVB group. CONCLUSION: Perioperative multiple-injection thoracic paravertebral blocks with bupivacaine containing epinephrine provided effective pain relief and a significant reduction in opioid requirements. This approach may also contribute to earlier postoperative ambulation after video-assisted thoracic surgery.

Intraoperative infusion of dexmedetomidine reduces perioperative analgesic requirements.

PURPOSE: This prospective, randomized, double-blind study was designed to assess whether intraoperative infusion of dexmedetomidine provides effective postoperative analgesia. Postoperative pain scores and morphine consumption were compared in a treated group and a placebo group, both of which received patient-controlled morphine after total abdominal hysterectomy. METHODS: Fifty women were randomly assigned to two groups. Group D (n = 25) received a loading dose of dexmedetomidine 1 mug.kg(-1) iv during induction of anesthesia, followed by a continuous infusion at a rate of 0.5 mug.kg(-1).hr(-1) throughout the operation. Group P (n = 25) received a volume-matched bolus and infusion of placebo (0.9% saline). For each case, heart rate, peripheral oxygen saturation, and systolic and diastolic blood pressure were recorded intraoperatively and for 48 hr postoperatively. Patients used a patient-controlled analgesia device to receive bolus doses of morphine after surgery. Total morphine consumption, pain scores, and sedation scores were recorded for the first 48 hr (two hours in the postanesthesia care unit and 46 hr on the ward). RESULTS: The groups were similar with respect to mean times to extubation of the trachea. Pain and sedation scores were also similar between groups at all corresponding times throughout the 48-hr period of observation. Group D patients consumed significantly less morphine in the postanesthesia care unit and on the ward (P < 0.05 and P < 0.01, respectively). Fewer patients in Group D experienced itching or nausea/vomiting (P < 0.05). CONCLUSION: Continuous iv dexmedetomidine during abdominal surgery provides effective postoperative analgesia, and reduces postoperative morphine requirements without increasing the incidence of side effects.

A comparison of effects of alfentanil, fentanyl, and remifentanil on hemodynamic and respiratory parameters during stereotactic brain biopsy.

The aim of this study was to compare the effects of 3 different sedative-analgesic regimens in patients with intracranial mass lesions undergoing stereotactic brain biopsy. A 135 outpatients with American Society of Anesthesiologists I to II were divided into 3 groups: group A (n = 45) received a loading dose of IV alfentanil 7.5 microg/kg followed by infusion rate of 0.25 microg/kg/min; group F (n = 45) received a bolus dose of 1 microg/kg IV fentanyl and repeated as needed; and group R (n = 45) received infusion of 0.05 microg/kg/min remifentanil. Target level of sedation was 3 to 4 of the Ramsay Sedation Scale. Systolic and diastolic blood pressure, heart rate, respiratory rate, peripheric oxygen saturation (SpO2), and end-tidal carbon dioxide were recorded at different stages of the procedures. The patients in group F had significantly lower mean heart rate than those in groups A and R, but this was not in the limits of the bradycardia. The patients in group A had significantly lower mean SpO2 than those in the other groups, but mean SpO2 values did not drop below 94%. There were no significant differences in end-tidal carbon dioxide and respiratory rate values among the groups. Our results suggest that all 3 regimens have relatively similar hemodynamic and respiratory responses. The use of bolus fentanyl technique caused less hemodynamic stability. The continuous infusion technique of remifentanil or alfentanil provided better control on hemodynamic parameters.

Elevation of serum cerebral injury markers correlates with serum choline decline after coronary artery bypass grafting surgery.

The aims of this study were to determine circulating choline status and its relationship to circulating levels of S-100beta protein and neuron-specific enolase, biochemical markers of cerebral injury and cognitive decline, after coronary artery bypass grafting (CABG) surgery. Preoperatively, patients scheduled for off-pump or on-pump CABG surgery had serum concentrations of 12.0+/-0.2 and 11.7+/-0.4 micromol/L free choline and 2640+/-65 and 2675+/-115 micromol/L phospholipid-bound choline, respectively. Serum free and bound choline levels decreased by 22-37% or 34-47% and 16-36% or 31-38% at 48 h after off-pump or on-pump surgery, respectively. Serum S-100beta and neuron-specific enolase increased from preoperative values of 0.083+/-0.009 and 6.3+/-0.2 microg/L to 0.405+/-0.022 and 11.4+/-0.8 microg/L, respectively, at 0 h postoperatively and remained elevated for 48 h after off-pump surgery. Serum free and bound choline concentrations were inversely correlated with the concentrations of S-100beta (r=-0.798; p<0.001 and r=-0.734; p<0.001) and neuron-specific enolase (r=-0.840; p<0.001 and r=-0.728; p<0.001). In conclusion, CABG surgery induces a decline in serum free and phospholipid-bound choline concentrations. The decreased serum choline concentrations were inversely correlated with the elevated levels of circulating cerebral injury markers. Thus, a decline in circulating choline may be involved in postoperative cognitive decline.

Spinal anesthesia in a patient with severe thoracolumbar kyphoscoliosis.

Patients with spine abnormalities, present unique challenges to the health care provider responsible for administrating sedation and anesthesia during surgical and technical procedures. Spinal deformities may cause difficulties with both tracheal intubation and regional anesthesia. This report describes the anesthetic management for two urological operations that were performed in a patient with extremely severe thoracolumbar kyphoscoliosis. After examining the risk factors, spinal block by injecting single dose local anesthetic solution to the intratechal space was chosen to provide anesthesia. It has been suggested that hyperbaric solution, which is of high density compared with cerebrospinal fluid, can safely produce blocks for many operations under spinal anesthesia. In the first procedure, intrathecal injection of 6 mg hyperbaric bupivacaine, a local anesthetic solution (1.2 ml total volume), resulted in inadequate motor and sensory blockade, but the successful motor and sensory blockade at the level of Th10 was achieved in a second attempt with 6.25 mg hypobaric bupivacaine (2 ml). Because of this unexpected effect of local anesthetic solution, in the second operation, the technique was changed to intrathecal injection of 12.5 mg hypobaric bupivacaine (4 ml), and the motor and sensory blockade at Th10 was achieved again. The patient reported satisfactory anesthesia each time, and developed no complications. In conclusion, spinal anesthesia can be successful even in cases of severe thoracolumbar kyphoscoliosis.

A new technique for superior hypogastric plexus block: the posteromedian transdiscal approach.

Superior hypogastric plexus block has been advocated for the treatment of cancer related pelvic pain. Neurolysis is usually established using the classical posterolateral approach in the prone position, in which correct placement of the needle is sometimes difficult due to vertebral anatomy and the patient's inability to lie prone. We describe an alternative posteromedian transdiscal approach under fluoroscopic guidance for the treatment of intractable pelvic pain in three patients, in whom the classical approach was not possible. The L5-S1 interdiscal space was identified with fluoroscopy. The needle was then introduced through the disc and advanced under lateral fluoroscopic control. After verifying correct needle placement, neurolysis was performed with 8 ml of 10% phenol solution. All patients had significant pain relief immediately after the block, lasting from 6 to 12 months, and their pain severity scores and opioid consumption were reduced by more than 50%. There were no complications such as discitis, disc rupture or nerve injury. Since this new posteromedian transdiscal approach provides easy access to the superior hypogastric plexus with a single puncture and with any patient position, it may be an alternative to the classical approach.

Effects of ketamine and thiopental on ischemia reoxygenation-induced LDH leakage and amino acid release from rat striatal slices.

Increased release of glutamate is thought to contribute to ischemia-induced neuronal damage. Since general anesthetics such as thiopental and ketamine are thought to provide some degree of cerebral protection, this study was intended to 1) compare the effectiveness of ketamine and thiopental on ischemia-induced tissue damage; and, if so, 2) determine whether attenuation of the increased amino acid release is the sole mechanism for the protective effects demonstrated. Striatal slices prepared from Wistar Albino rats were incubated in an ischemic medium for 1 hour followed by 5 hours in a reoxygenation (REO) medium. Ketamine and thiopental were added medium during ischemia and/or REO periods, and the medium was collected at the end of each incubation period for measurement of amino acid release and lactate dehydrogenase (LDH) leakage. Ischemia significantly increased amino acid release without altering LDH leakage. Ischemia-induced increments in glutamate and aspartic acid releases returned to control levels during REO, but LDH leakage increased (P > 0.001) during this period. Although ketamine (100 microM) and thiopental (100 microM) failed to decrease ischemia-induced excitatory amino acid release, they protected the slices against REO-induced LDH leakage. Ketamine, but not thiopental, was effective even if added after ischemia (P < 0.05). These results indicate that ketamine and thiopental protect the slices against REO-induced LDH leakage. However, mechanisms other than attenuation of the enhanced glutamate release might be responsible for their protective effects.

[Blockade of ganglion impar through sacrococcygeal junction for cancer-related pelvic pain]. / Kansere bagli pelvik agrida sakrokoksigeal bileske yolu ile uygulanan impar gangliyon blogu.

Impar ganglion block provides pain relief in patients who suffer from sympathetically mediated pain arising from disorders of viscera and somatic structures within the pelvis and perineum. We performed impar ganglion blockade through sacrococcygeal junction instead of anococcygeal ligament in 9 patients who had localized perineal pain of visceral origin. All the blocks which were performed through sacrococcygeal junction without bending the needle under fluoroscopic guidance were easy to perform without any complication. Pain intensity by Visual Analogue Scale, daily opioid requirements, and complications related to opioids were evaluated before the procedure, and for 2 months after the procedure. The intensity of pain, daily opioid requirement and the complication related to the opioids were significantly decreased in 8 patients. We suggest that impar ganglion block through sacrococcygeal junction appears to be safe and effective procedure in the management of perineal pain related to malignancy.