[Controlled hypotension for tympanoplasty: comparison between remifentanil and combination of alfentanil and sodium nitroprusside]. / Timpanoplasti olgularinda kontrollü hipotansiyon: Remifentanil ve alfentanil-sodyum nitroprusid kombinasyonunun karsilastirilmasi.

OBJECTIVES: We compared the efficacy of remifentanil and the combination of alfentanil and sodium nitroprusside on controlled hypotension and bleeding at surgical site. PATIENTS AND METHODS: Thirty ASA I-II patients undergoing tympanoplasty were randomly assigned to remifentanil and alfentanil-sodium nitroprusside groups, equal in number. Anesthesia was induced with remifentanil or alfentanil combined with propofol and rocuronium, and maintained with remifentanil or alfentanil-sodium nitroprusside infusions combined with propofol. All patients were ventilated with a mixture of 33% O2 and 66% N2O. Invasive mean arterial blood pressure, heart rate, peripheral oxygen saturation, the amount of bleeding at surgical site, and blood gas values were recorded. RESULTS: Controlled hypotension was achieved at a target mean arterial pressure of 60+/-5 mmHg in both groups. Compared to the baseline levels, heart rate values were lower in the remifentanil group (p<0.05), and similar in the sodium nitroprusside group (p>0.05). The amount of bleeding and the dryness of the surgical site were similar in two groups. PaCO2 and pH values differed significantly between the two groups at perioperative 1 and 2 hours and in the postoperative 30th minute (p<0.05), but the difference was not clinically significant. CONCLUSION: Our results suggest that remifentanil is effective in obtaining controlled hypotension without an additional potent hypotensive agent and provides appropriate surgical conditions by reducing the amount of bleeding.

Thoraco-omphalopagus conjoined twins detected at as early as 9 weeks of gestation: transvaginal two-dimensional ultrasound, color Doppler and fetoplacental Doppler velocity waveform findings.

Here we report a case of conjoined twins that were diagnosed antenatally by routine two-dimensional transvaginal ultrasound examination at as early as the 9th week of gestational age. The fetuses were of the thoraco-omphalopagus type and were sharing the liver, as confirmed by color Doppler. There was a reversed flow in the single ductus venosus of the twins. Umbilical arterial and venous blood flow waveform did not show any abnormality for this gestational age. This case demonstrated the possibility of making an accurate diagnosis of conjoined twins in the first trimester by transvaginal two-dimensional ultrasound and color Doppler examination. Although conjoined twins were described at first trimester before, fetoplacental Doppler waveform findings at this gestational age have been described very rarely. This case demonstrated the possibility of making an accurate diagnosis of conjoined twins and delineating the extent of organ sharing in the first trimester, and early diagnosis can help the parents with the option for pregnancy termination. The importance of expert early vaginal sonography and color Doppler findings is emphasized.