Comparison of two sedation protocols on intraocular pressure and hemodynamic responses during colonoscopy.

OBJECTIVE: Colonoscopy is one of the most frequently performed interventional endoscopic procedures for diagnosis and treatment. During the procedure, the increase in intraabdominal pressure can cause undesirable spikes in intraocular pressure. In the literature, there are no studies on agent combinations that cause the least effect on intraocular pressure and hemodynamic response in colonoscopic procedures, which are performed more frequently in the elderly, the patient group at the greatest risk for glaucoma. This study aimed to compare ketamine-propofol and ketamine-midazolam protocols in terms of their effects on hemodynamic parameters and intraocular pressure. MATERIALS AND METHODS: The research was a randomized clinical controlled double-blind study. The study was conducted on 60 healthy adults who underwent elective colonoscopy. Ketamin-midazolam and ketamine-propofol combinations were used. Hemodynamic parameters, intraocular pressures at five different times, and the satisfaction levels of the endoscopist and the patient were recorded. RESULTS: In both groups, there was a statistically significant difference between the pre-procedure intraocular pressure values and the values at the 1st minute of the procedure and at recovery (p<0.05). No statistically significant difference was found between the intraocular pressure values of the study groups at any time point (p>0.05). CONCLUSIONS: Both combinations can be used safely. The combination of ketamine and propofol in subanesthetic doses provides better sedation without disturbing the hemodynamics and is preferable.

Propofol-ketamine combination: a choice with less complications and better hemodynamic stability compared to propofol? On a prospective study in a group of colonoscopy patients.

BACKGROUND AND AIMS: In this study, we compared duration for reaching desired Ramsay Sedation Score (RSS) and postoperative recovery according to Modified Aldrete Score (MAS) of propofol and propofol-ketamine combination in a group of colonoscopy patients. Rates of cardiovascular, respiratory, laryngospasm, visual and nausea/vomiting complications were also compared as secondary outcomes. METHODS: This is a double-blinded prospective randomized controlled trial. 95 patients were included and blocked randomized to either propofol (GroupP, n: 47) or propofol-ketamine (GroupPK, n: 48). GroupP patients received 0.5 mg/kg propofol and GroupPK received 0.5 mg/kg ketamine-propofol. Subjects were monitorized noninvasively preoperatively and every 5 min during procedure. RSS was recorded for every minute before starting procedure and for every 5 min during procedure. Recovery after colonoscopy was evaluated according to MAS. Same observer checked for MAS just after procedure in postoperative 1 min and for every 3 min during follow-up. Postoperative respiratory depression was defined as rate <10/min, hypercapnia/hypercarbia-arterial CO2 tension >50 mmHg or SO2 <90 while hypotension was defined as a decrease of 20 % in mean blood pressure compared to initial values. RESULTS: GroupPK patients needed shorter duration for achieving RSS ≥ 4 (p: 0.038) but longer duration for achieving MAS ≥ 9 (p: 0.005). GroupP's intraoperative blood pressures and heart rates were significantly lower compared to initial values. We observed that respiratory depression (19.1 vs 0 %, p: 0.001), hypotension (29.8 vs 10.4 %, p: 0.018), and nausea/vomiting (17 vs 4.2 %, p: 0.041) were significantly more common in GroupP. CONCLUSION: Propofol-ketamine combination is an advantageous choice in means of achieving sedation in a shorter period of time, a better hemodynamic stability, less nausea and vomiting and respiratory complication rates. Yet it seems that this choice might be related with longer recovery duration.

Comparison of propofol-remifentanil and propofol-ketamine combination for dilatation and currettage: a randomized double blind prospective trial.

OBJECTIVE: The purpose of this study was to compare the propofol-remifentanil combination and propofol-ketamine combination for Dilatation and Curettage (DC) procedure. PATIENTS AND METHODS: This prospective, double blind, and randomized study comprised 81 female patients undergoing diagnostic DC. Patients were randomly allocated to one of two groups; propofol-remifentanil (Group PR, n= 44) or propofol-ketamine (Group PK, n= 37). The level of sedation was assessed with the Ramsay Sedation Score (RSS). The patients' RSS scores were maintained at 4-5 with an additional 0.5 mg/kg bolus dose of propofol. Heart rate (HR), mean blood pressure (MBP), peripheral oxygen saturation (SpO2), and RSS were recorded. The Modify Aldrete Score (MAS) was used for postoperative recovery evaluation, and the time to reach MAS score of 10 was recorded. Total dose of propofol, procedure time, side effects, and satisfaction scores of patient and surgeon were also recorded. RESULTS: The mean HR and MBP values of Group PR were lower than those of Group PK, at all recording times. Sedation levels were significantly higher in Group PK. The total dose of propofol consumed was significantly higher in Group PR. The recovery time of Group PK was significantly longer than that of Group PF (p<0.05). Nausea-vomiting and bradycardia were more frequent in the Group PR. There was no difference in patient and surgeon satisfaction between the two groups. CONCLUSIONS: Ketamine-propofol combination provides better hemodynamic stability and better quality of sedation than propofol-remifentanil combination. Ketamine still seems as an advantageous and safe drug for such procedure.

An evaluation of the effects of perioperatively administered fluids on ischemia/reperfusion injury.

OBJECTIVE: To investigate the effects of normal saline (0.9% NaCl) and 6% Hydroxyethyl Starch 130/0.4(HES) solution on Ischemia/Reperfusion (I/R) injury in patients undergoing knee arthroscopy operations with spinal anesthesia using a tourniquet. METHODS: The study comprised 48 ASA I-II patients undergoing knee arthroscopy with spinal anesthesia using a tourniquet. The patients were randomised into two groups and after standard monitoring two venous lines were introduced to obtain blood samples and to give intravenous therapy. In the control group (Group A) (n=21) 0.9% NaCl, 10 ml/kg/hours and in the study group (Group B) (n=19) 6% Hydroxyethyl Starch 130/0.4, 10 ml/kg/hours infusion were administered. Spinal anesthesia was applied with 12.5 mg hyperbaric bupivacaine to all patients. The tourniquet was applied and the operation was started when the sensorial block level reached T10 dermatome. Blood xanthine oxidase (XO) and malondialdehyde (MDA) levels as an indicator of ischemia and reperfusion injury were measured in samples before fluid infusion (t1), before tourniquet application (t2), 1 minute before tourniquet release (t3), and at 5 (t4) and 15 (t5) minutes after tourniquet release. RESULTS: No difference was observed between the two groups in respect of demographic parameters, the highest block level, duration before tourniquet application and tourniquet duration (p>0.05). The MDA level after tourniquet application and 15 minutes after tourniquet release was lower in Group B (p<0.05). XO levels were not different (p>0.05). CONCLUSION: In this study 6% Hydroxyethyl Starch 130/0.4 solution reduced MDA level which is an indicator of lipid peroxidation. 6% Hydroxyethyl Starch 130/0.4 solution may be beneficial for Ischemia/reperfusion injuries.

The postoperative analgesic efficacy of intraperitoneal bupivacaine compared with levobupivacaine in laparoscopic cholecystectomy.

BACKGROUND: The aim of this randomized controlled study was to compare the postoperative analgesic efficacy of intraperitoneal bupivacaine versus levobupivacaine in patients undergoing laparoscopic cholecystectomy. METHODS: We randomly divided 90 patients undergoing elective laparoscopic cholecystectomy into 3 groups. A dose of 0.125% bupivacaine (Group B) 80 ml or 0.125% levobupivacaine (Group L) 80 ml or 0.09% NaCl (Group P) 80 ml was instilled intraperitoneally at the end of the procedure, before removal of the trocars. All patients had a standard anesthetic. Tramadol was administered intravenously via a patient controlled analgesia pump as a rescue analgesic in all patients. Postoperative pain scores were assessed at 30 minutes, 1, 2, 4, 6, 12 and 24 hours after surgery by using a visual analog scale. The primary end point of this study was to compare tramadol consumption of the three groups at the postoperative 24 h. Total tramadol consumption, first analgesic requirement time and adverse effects were recorded. RESULTS: Group B experienced significantly less pain (P < 0.01) than the placebo group at 6 h, 12 h and 24 h postoperatively during rest. Group L registered significantly lower visual analog scale scores (p < 0.01) than the placebo group at 12 h during rest. During movement, visual analog scale pain scores were lower in group B than Group P (P < 0.01). Additionally, total tramadol consumption was significantly lower in Group B than the other groups. First analgesic requirement time was shorter in the placebo group compared with group B and group L (P < 0.05). There was no significant difference between the groups with respect to right shoulder pain, total nausea and vomiting. CONCLUSION: Intraperitoneal instillation of bupivacaine 0.125% 80 ml (100 mg) is more effective than levobupivacaine 0.125% 80 ml (100 mg) in reducing the postoperative pain after laparoscopic cholecystectomy.

Difficult airway due to protruding macroglossia in a child with lymphangioma.

Lymphangiomas, or cystic hygromas, are relatively uncommon congenital malformations of the lymphatic system that usually present during the first years of childhood. They are rare in adults. A search of the literature on MedLine revealed only few reports about lymphangioma as a cause of difficult airway management after the neonatal period. Herein, we present a case of difficult intubation due to protruding macroglossia in a 5-year-old girl diagnosed with recurrent lesions of lymphangioma. We also discuss possible problems in airway protection, drug choice, and post-operative follow-up associated with surgical excision of these lesions.

Effects of isoflurane on nitric oxide metabolism and oxidant status of guinea pig myocardium.

BACKGROUND: Volatile anesthetics (VAs) have been shown to enhance myocardial recovery during reperfusion, the mechanism of which has not been clarified yet. It has been supposed that this effect of VAs may appear through antioxidative mechanisms. METHODS: Thirty guinea pigs were used in the study. There were three groups with 10 animals in each: I - control, II - isoflurane+oxygen and III - oxygen. Isoflurane (2.0% v/v) and oxygen (100%) mixture was given to the animals via a face mask in the isoflurane+oxygen group at the rate of 21 per min for 30 min a day for three consecutive days. In the oxygen group, oxygen alone (100%) was given under the same conditions as in the isoflurane+oxygen group. At the end of the experiments, the animals were killed and their hearts were removed. In the heart tissues, nitric oxide synthase (NOS) activity, nitric oxide (NO) pool (NO*+NO2-) and malondialdehyde (MDA) levels were measured. RESULTS: NOS activity was found to be higher and the NO pool lower in the isoflurane+oxygen group compared with those of control and oxygen groups. In the oxygen group, MDA level was found to be higher compared to the other groups. There was, however, no significant difference between MDA levels of the control and isoflurane+oxygen groups. CONCLUSION: Our results suggest that isoflurane prevents peroxidation reactions in heart tissue, possibly by scavenging toxic oxygen radicals produced under hyperoxygenation conditions as occurs with general anesthesia.