Characteristics of the injuries of Syrian refugees sustained during the civil war.

BACKGROUND: During a war, many civilians are severely injured by firearms, bombs, and shrapnel. The triage of war injuries involves difficult and complicated processes requiring surgical procedures and patient monitoring in the Intensive Care Unit (ICU) of hospitals. In this study, we examine the demographic, traumatic, and critical care characteristics of cases injured during the civil war in Syria and requiring emergency surgery. METHODS: Electronic data of the traumatic, surgical, and ICU monitoring features of 707 patients admitted to Kilis Public Hospital between March 2012 and January 2013 were analyzed retrospectively RESULTS: Most of the patients reported having been injured due to firearms (83.75%). Of the 707 cases studied in this work, 93.2% was male. Male patients reported a mean age of 26.1±12.1 years, while pediatric cases reported a mean age of 11.7±3.41 years. The most frequently injured region of the body was the head-neck region (52.7%). The New Injury Severity Score (NISS) of the cases was 42.5±11.2 and their American Society of Anesthesiologists (ASA) score was 3.2±0.7. The number of cases with intraoperative exitus was 7, while the number of cases who had undergone damage control surgery was 204. The number of cases hospitalized in the ICU during the postoperative period was 233, and the average hospitalization duration in the ICU was 4.67±1.32 days. Among survivor patients, the first 24-hour invasive measurements (i.e., pH, hemoglobin, body temperature, and mean arterial blood pressure) and international normalized ratio were found to be high. The number of blood products used for surviving patients was fewer relative to that used for non-surviving patients, and these NISS of these patients was 29.7±10.1. The mortality rate of all patients followed up in the ICU after emergency surgery was 45%, and neurosurgical cases showed the lowest level of survival (24.1%). CONCLUSION: The results of this study indicated that head-neck, chest-abdomen, and multiple body injuries are the most widely seen among civilians brought to Turkey because of gunshot injuries sustained during the Civil War in Syria. The number of emergency operations performed in the study sample was high, and critical care follow-up durations were long. In addition, the NISS and ASA scores of mortal cases were fairly high.

Dexmedetomidine: an alternative for epidural anesthesia in tension-free vaginal-tape surgery.

PURPOSE: Anesthetic management of tension-free vaginal-tape (TVT) procedures is sometimes difficult to deal with, especially when surgeons request a cough test. Dexmedetomidine has unique sedative and analgesic properties while having minimal respiratory effects, making it suitable for perioperative use in monitored anesthesia care. We aimed to compare dexmedetomidine and epidural anesthesia in TVT patients. METHODS: Forty-nine women [American Society of Anesthesiologists (ASA 1-3)] with genuine stress incontinence confirmed by preoperative bladder function studies were included in this double-blind, randomized study. The patients were randomly assigned to one of two groups: group D received 0.5 µg/kg dexmedetomidine IV applied as bolus over 10 min and continued with 0.5 µg/kg/h infusion, and local anesthesia (lidocaine 2% with epinephrine) performed by the surgeon. Group E received epidural anesthesia with 15 ml of 0.25% bupivacaine + 100 µg fentanyl. Patients were monitored every 5 min for mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation, respiratory rate, sedation, and intraoperative and postoperative pain. Ability to cough was also evaluated by the surgeon. RESULTS: There was no difference in ability to cough, and this was evaluated by the surgeon as adequate, and there was no difference in scores between groups. Significant decreases in MAP and HR were observed 10 min after the start of surgery in group D compared with group E, and they were significantly decreased until first and second postoperative hours, respectively (p < 0.05). None of the patients had respiratory rate decrease or apnea. Side effects encountered postoperatively were similar. CONCLUSION: Dexmedetomidine can be an alternative to epidural anesthesia in TVT procedure requiring cough test.

The efficiency and duration of the analgesic effects of musical therapy on postoperative pain.

OBJECTIVES: The aim of this study was first to find out the effect of music therapy on postoperative analgesia and second to determine the duration of its effect. METHODS: Seventy patients who were undergoing elective cesarean delivery were enrolled. The patients were randomly allocated into two groups as follows: In Group 1, patients listened to music through a headphone for one hour after surgery, while in Group 2, patients did not listen to any music during the same period. In the postanesthesia care unit, patients were connected to a Patient Controlled Analgesia (PCA) device. The PCA device (tramadol 3 mg/ml) was set to deliver a bolus of 20 mg, with a lockout interval of 15 min and 4-hour maximal dose of 150 mg. Postoperative pain was assessed with a visual analog scale (VAS) and consumption of tramadol was recorded at 4, 8, 12, 16, 20 and 24 hours. RESULTS: There was a significant decrease in Group 1 with respect to PCA delivery frequency at the 4th hour postoperatively (p<0.05). Concerning the postoperative tramadol consumption, values measured at the 4th hour were significantly lower in Group 1 (p<0.05). The total amount of tramadol consumption and additional analgesic use in the postoperative 24 hours were again lower in Group 1 when compared with Group 2 (p<0.05). All VAS values were lower in Group 1 when compared with Group 2 (p<0.05). CONCLUSION: We suggest that music therapy given after surgery decreases postoperative pain in the first 24 hours and the analgesic consumption during the first four hours.

Epileptic seizure during anaesthesia induction with etomidate.

In this report a 20-year-old male patient who had suffered tonic-clonic seizure after a single induction dose of etomidate until a bispectral index value of 60 is presented. Our best knowledge, this case is the first report of pure etomidate (with induction dose) induced generalized tonic clonic seizure proven with EEG. Anaesthesiologists should be careful against such a complication even in the induction stage of anaesthesia during etomidate use.

[Pasha-Cath in the treatment of post-thoracotomy pain syndrome]. / Posttorakotomi agri sendromu tedavisinde Pasha-Cath uygulamasi.

Post-thoracotomy pain syndrome is a chronic pain syndrome and is seen in approximately 5-65% of patients after thoracotomy. Post-thoracotomy pain syndrome is generally considered to be neuropathic pain due to intercostal nerve injury. A 21- year-old male patient experienced pain radiating along the incision after the thoracotomy operation. Allodynia and hyperalgesia were determined in the upper part of the incision; visual analogue scale (VAS) score was 10. Gabapentin and amitriptyline were started as medical treatment. Three months later, the patient complained of concentration difficulty at work and in daily life. Medical therapy was planned again. In view of the persisting complaints, epidural pulse radio frequency with Pasha-Cath was scheduled. After 3 weeks and also at 3 months, the VAS was 2. After 6 months, VAS remained at 2. As a result, we concluded that epidural pulse radio frequency with Pasha-Cath is an alternative and effective choice of treatment in post-thoracotomy pain syndrome when the medical treatment alone is not sufficient.

A comparison of dexmedetomidine versus midazolam for sedation, pain and hemodynamic control, during colonoscopy under conscious sedation.

OBJECTIVE: The intent of our study was to compare the effects of dexmedetomidine versus midazolam on perioperative hemodynamics, sedation, pain, satisfaction and recovery scores during colonoscopy. MATERIAL AND METHODS: A total of 60 ASA I-II patients, between 20 and 80 years of age were included in the study. Patients were randomly assigned to two groups. Midazolam 0.05 mg kg(-1) and fentanyl citrate 1 microg kg(-1) were administered intravenously to cases in Group I (n = 30). An initial loading dose of 1 microg kg(-1) dexmedetomidine was administered intravenously in 10 min to cases in Group II (n = 30) before the procedure and as a continuous infusion dose of 0.5 microg kg(-1) h(-1) just before the procedure started. Also 1 microg kg(-1) fentanyl citrate was administered intravenously immediately before the procedure. Peripheral oxygen saturation (S(pO2)), mean arterial pressure (MAP), heart rate (HR), Ramsay Sedation Scale (RSS), Numeric Rating Scale (NRS) scores and colonoscopist satisfaction scores of the cases were recorded. RESULTS: Although statistically significant values were not detected between the two groups with regard to mean arterial pressure, in Group I heart rates were higher and S(pO2) scores were lower in a statistically significant manner. When the groups were compared with regard to RSS, the RSS scores of Group I at the 10th and 15th minutes were significantly lower than Group II. There was no statistically significant difference between the two groups when compared with regard to NRS scores. Satisfaction scores were significantly lower in Group II. CONCLUSION: Dexmedetomidine provides more efficient hemodynamic stability, higher Ramsay sedation scale scores, higher satisfaction scores and lower NRS scores in colonoscopies. According to our results we believe that dexmedetomidine can be used safely as a sedoanalgesic agent in colonoscopies.

A complication during caudal steroid injection.

BACKGROUND AND OBJECTIVE: Epidural injections in the lumbar spine are provided by caudal, lumbar interlaminar or transforaminal routes. Caudal epidural steroid injections are often used for low back pain. Fluoroscopic guidance has been frequently cited as a requirement for this procedure. In this case report, we demonstrate the importance of fluoroscopic guidance during caudal epidural injection. CASE REPORT: A 60 years old male patient was admitted to our Algology Department for low back pain. After physical examination caudal epidural steroid injection was planned. The caudal space was identified under fluoroscopic control initially using an anteroposterior projection. After the resultant epidurogram demonstrated vascular spread along the caudal epidural space the needle was withdrawn and the procedure was completed after reinserting the needle. CONCLUSION: A careful real time fluoroscopic monitoring should be applied with the injection of opaque material to minimize the risk of vascular injection.

A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy.

BACKGROUND: Gabapentin and ketamine are popular analgesic adjuvants for improving perioperative pain management. We designed this double-blind, placebo-controlled study to test and compare the preventive effects of perioperative ketamine and gabapentin on early and chronic pain after elective hysterectomy. METHODS: Sixty patients undergoing abdominal hysterectomy were randomly assigned to 1 of the following 3 groups: control group received oral placebo capsules and bolus plus infusion of saline; ketamine group received oral placebo capsules and, before incision, 0.3 mg/kg IV bolus and 0.05 mgxkg(-1)xh(-1) infusion of ketamine until the end of surgery; and gabapentin group received oral gabapentin 1.2 g and bolus plus infusion of saline. The anesthetic technique was standardized, and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Patients were questioned at 1, 3, and 6 mo after surgery for chronic postoperative pain. RESULTS: Postoperative pain scores were significantly lower in the gabapentin group compared with the ketamine and control groups, and patient-controlled analgesia morphine use was significantly reduced in both treatment groups (versus control group) (P < 0.001). Total patient-controlled analgesia morphine use was decreased by 35% and 42% in the ketamine and gabapentin groups, respectively, compared with the control group (P < 0.001). Patient satisfaction with pain treatment was significantly improved in the ketamine and gabapentin groups compared with the control group (P < 0.001). The incidence of incisional pain and related pain scores at the 1-, 3-, and 6-mo follow-up were significantly lower in the gabapentin group compared with the ketamine and control groups (P < 0.001). CONCLUSION: Gabapentin and ketamine are similar in improving early pain control and in decreasing opioid consumption; however, gabapentin also prevented chronic pain in the first 6 postoperative months.

The analgesic effect of paracetamol when added to lidocaine for intravenous regional anesthesia.

BACKGROUND: In this study, we evaluated the effect of paracetamol on sensory and motor block onset time, tourniquet pain, and postoperative analgesia, when added to lidocaine in IV regional anesthesia (IVRA). METHODS: Sixty patients undergoing hand surgery were randomly and blindly divided into three groups. All groups received IVRA lidocaine (3 mg/kg) diluted with saline to a total volume of 40 mL. Group 1 received IVRA lidocaine plus IV saline, Group 2 received IVRA lidocaine and paracetamol (300 mg) admixture plus IV saline, and Group 3 received IVRA lidocaine plus IV paracetamol (300 mg). Sensory and motor block onset time, tourniquet pain, and analgesic use were assessed during operation. After tourniquet deflation, visual analog scale (VAS) scores at 1, 2, 4, 6, 12, and 24 h, the time to first analgesic requirement, total analgesic consumption in first 24 h, and side effects were noted. RESULTS: Onset of motor block was shorter and recovery of motor and sensory block was significantly longer in Group 2 (P < 0.05). Intraoperative VAS scores at intraoperative 20, 30, and 40 min were significantly lower in Group 2 (P < 0.05). Intraoperative fentanyl consumption (78 +/- 12, 58 +/- 14, 78 +/- 11 microg, respectively) and the number of patients who required fentanyl for tourniquet pain (13 patients, 3 patients, 9 patients, respectively) were significantly less in Group 2 (P < 0.05). Time to postoperative fentanyl administration was also prolonged (15 +/- 6, 25 +/- 5, 15 +/- 4 min, respectively) in Group 2 (P < 0.05). The quality of surgical anesthesia was better in Group 2 (P < 0.05). Postoperative VAS scores and time of initial analgesic requirement were similar among groups; however, the total amount of diclophenac use was less in Group 2 (P < 0.05). CONCLUSION: The addition of paracetamol during IVRA with lidocaine decreased tourniquet pain, increased anesthesia quality, and decreased postoperative analgesic consumption.

The effects of gabapentin on acute and chronic pain after inguinal herniorrhaphy.

BACKGROUND AND OBJECTIVE: To find out whether preoperative gabapentin use had a favourable effect on long-term postoperative pain in patients undergoing inguinal herniorrhaphy. METHODS: Sixty male patients--aged 20-40 years--who were scheduled for unilateral inguinal herniorrhaphy under spinal anaesthesia were included in this prospective, randomized, double-blind study. The patients were randomly allocated to two groups: the gabapentin group (n=30) received single-dose 1.2 g oral gabapentin 1 h before surgery, and the placebo group received a placebo capsule instead. Spinal anaesthesia was performed with heavy bupivacaine, and all operations were performed by the same surgeon with the same technique. Postoperative analgesia was evaluated during sitting and lying with a visual analogue scale. Assessment of postoperative pain at 1, 3 and 6 months was carried out with an 11-point numerical rating scale; 0 indicating 'no pain' and 10 indicating 'worst pain imaginable'. Patients who had numerical rating scale scores of more than 0 were further evaluated with regard to the impact of pain on their daily activities. RESULTS: When compared with the placebo group, the gabapentin group displayed significantly lower visual analogue scale scores (lying and sitting) and total tramadol consumption at 8, 12, 16, 20 and 24 h after surgery (P<0.05) and higher postoperative patient satisfaction scores (P<0.05). Numerical rating scale scores at 1, 3 and 6 months after surgery were lower in the gabapentin group than in the placebo group (P<0.05). The number of patients whose daily activities were adversely affected by pain was smaller in the gabapentin group at the first month; however, the two groups were found to be similar at 3 and 6 months. CONCLUSION: We conclude that preoperative single-dose gabapentin decreases the intensity of acute postoperative pain, tramadol consumption and the incidence and intensity of pain in the first 6 months after inguinal herniorrhaphy.

The comparison of the effects of different doses of levobupivacaine infiltration on wound healing.

UNLABELLED: INTRODUCTION-AIM: The easiest method in postoperative analgesia is the infiltration of the wound with local anesthetic drugs. Although many local anesthetic drugs have been used for this type of infiltration, studies on levobupivacaine are rare. The aim of this study was to investigate the effects of different concentrations of levobupivacaine infiltration on wound healing. METHOD: Forty female Wistar-Albino rats (280-300 g) were included in the study, which were randomly separated into four groups. Rats were infiltrated with 1.25 mg/mL levobupivacaine in group L(1.25) (n = 10), with 2.50 mg/mL levobupivacaine in group L(2.5) (n = 10), with 3.75 mg/mL levobupivacaine in group L(3.75) (n = 10), and with normal saline in control group (n = 10). Breaking-strength measurements, levels of hydroxyproline, and fibrotic index were evaluated in the tissue samples taken from the rats. RESULTS: When the breaking-strength measurements were evaluated, we have found a significant difference between the control and the study groups (p < 0.05). In the intergroup comparison the difference between groups L(1.25) and L(3.75) was statistically significant (p < 0.05). In all of the levobupivacaine groups the levels of hydroxyproline were higher compared to the control group. Also significant differences were observed between groups L(1.25) and L(2.5) and groups L(1.25) and L(3.75) (p < 0.05). The levels of tissue fibrotic index were higher in all of the levobupivacaine groups compared to the control group (p < 0.05) and also a difference was observed between groups L(1.25) and L(3.75) in terms of tissue fibrotic index (p < 0.05). CONCLUSION: We have concluded that levobupivacaine used in clinical doses have a significant effect on the fastening of wound healing and this effect increases with an increase in the concentration of the levobupivacaine. We believe that levobupivacaine will be more widely preferred in the near future in the postoperative analgesia.

Ecthyma-gangrenosum-like lesions associated with methicillin-resistant Staphylococcus aureus infection.

Ecthyma gangrenosum (EG) manifests as a skin lesion and is commonly associated with Pseudomonas aeruginosa septicemia in immunocompromised patients. Other viral, fungal and bacterial agents can also cause EG. The first clinical observation is grouped vesicles with surrounding erythema. Within a few days, they evolve into a gangrenous ulcer with a black/gray eschar surrounded by an erythematous halo. Herein, we present a patient with chronic obstructive pulmonary disease who developed EG-like lesions due to methicillin-resistant Staphylococcus aureus infection while he was in the intensive care unit.