Chrononutrition in Critical Illness.

Circadian rhythms in humans are biological rhythms that regulate various physiological processes within a 24-hour time frame. Critical illness can disrupt the circadian rhythm, as can environmental and clinical factors, including altered light exposure, organ replacement therapies, disrupted sleep-wake cycles, noise, continuous enteral feeding, immobility, and therapeutic interventions. Nonpharmacological interventions, controlling the ICU environment, and pharmacological treatments are among the treatment strategies for circadian disruption. Nutrition establishes biological rhythms in metabolically active peripheral tissues and organs through appropriate synchronization with endocrine signals. Therefore, adhering to a feeding schedule based on the biological clock, a concept known as "chrononutrition," appears to be vitally important for regulating peripheral clocks. Chrononutritional approaches, such as intermittent enteral feeding that includes overnight fasting and consideration of macronutrient composition in enteral solutions, could potentially restore circadian health by resetting peripheral clocks. However, due to the lack of evidence, further studies on the effect of chrononutrition on clinical outcomes in critical illness are needed. The purpose of this review was to discuss the role of chrononutrition in regulating biological rhythms in critical illness, and its impact on clinical outcomes.

[Comparison of the Multiplex Real Time Polymerase Chain Reaction Method Directly from Whole Blood and from Blood Culture Bottle with the Conventional Method for the Etiological Diagnosis in Patients with Pre-Diagnosis of Sepsis]. / Sepsis Ön Tanili Hastalarda Tam Kandan ve Kan Kültür Sisesinden Multipleks Gerçek Zamanli Polimeraz Zincir Reaksiyonu ile Hizli Etken Tayininin Konvansiyonel Yöntemlerle Karsilastirilmasi.

In this study, it was aimed to evaluate the use of multiplex real time polymerase chain reaction (RtPCR) method, directly from whole blood and blood culture bottles of intensive care unit patients with a pre-diagnosis of sepsis for the determination of the causative agent by comparing it with the conventional method. The study was carried out prospectively between November 2019 and August 2020. Ninety patients hospitalized with a pre-diagnosis of sepsis were included in the study. Samples were collected simultaneously with aseptic technique as whole blood and at least two sets of blood cultures. Blood culture bottles were monitored by the BACT/ALERT 3D (bioMerieux, France) instrument. Blood culture bottles were studied both by Sepsis Pathogens Panel Kit v1 (Anatolia, Turkey) using the multiplex Rt-PCR and with the conventional culture methods. The duration of detection and reporting of the multiplex Rt-PCR methods were compared with the conventional method. In this study, a total of 90 whole blood samples and 280 blood culture bottles were collected from the patients. It was found that 73 (81%) patients had already been administered antibiotic treatment at the time of blood sampling. Conventional blood culture was accepted as the gold standard in the diagnosis of sepsis. Rt-PCR performed from blood culture bottles was found to have a sensitivity of 89.58%; specificity of 57.14%; positive predictive value of 70.49%; negative predictive value of 82.76% and accuracy of 74.44% (p= 0.019). On the basis of the bacterial species, the sensitivity of the Rt-PCR method was determined to be between 66.7-100% and the specificity was between 86.6-100%. The Rt-PCR performed from whole blood, was found to have a sensitivity of 11.67% and a specificity of 96.67%; positive predictive value of 87.50%; negative predictive value of 35.37% and accuracy of 40% (p= 1.684). In this study, the duration of reporting of blood culture results was in average 116:50 hours, that of PCR from blood culture bottles was 80:57 hours, and that of PCR from whole blood samples was 15:38 hours (p<0.001). It was determined that the PCR from whole blood shortened the reporting time by an average of 101:12 hours (approximately four days), and that the PCR from blood culture bottles shortened the reporting time by an average of 35:53 hours (1.5 days) compared to the conventional method. In this study, the results determined by the Sepsis Pathogens Panel Kit v1 (Anatolia, Turkey) performed from blood culture bottles were superior compared to the conventional method. It has been determined that improvement is required for the usage of the sepsis kit directly from whole blood. On the other hand, considering the species detected by the blood culture method and not by the assay, the species range detected by the multiplex assay panel needs to be improved.

A complicated pregnancy: Eclampsia or COVID-19?

Pregnant women may be infected with SARS-CoV-2 virus and develop serious complications of the disease. Covid-19 causes primarily a respiratory system infection but can also affect cardiovascular, renal, gastrointestinal, and neurological systems. Cardiovascular involvement includes new onset hypertension, myocarditis, cardiomyopathy, pulmonary embolism, and pre-eclampsia like syndrome. We report a confirmed Covid-19 pregnant case presented with eclampsia to the emergency department and undergone emergent cesarean section. Following surgery, she was admitted to the intensive care unit due to hypoxemia and hypertension. After observing lymphopenia and high CRP level with hypoxemia, radiological imaging revealed typical findings for viral pneumonia and nasopharyngeal swab, which was not carried out at admission, was positive for Covid-19. On the 20th hour of follow-up, she became hypotensive requiring noradrenalin infusion. Echocardiography diagnosed cardiomyopathy with left ventricular ejection fraction of 35-40 % with high levels of NT pro-BNP, hs-troponin, and CK-MB in the patient. Covid-19 should be considered in complicated pregnancies. In complicated cases, a chest CT scan upon admission may aid in quickly detecting the presence of infection and preventing nosocomial spread of the virus. Cardiomyopathy could be found in pregnant patients with Covid-19 infection. Since cardiomyopathy can be seen in late pregnancy and early postpartum period, it is difficult to distinguish between viral and postpartum cardiomyopathy in these patients. Recognizing the infection earlier will help to anticipate the complications that might contribute to deterioration of the patients, perioperatively.

Antioxidant effects of dexmedetomidine against hydrogen peroxide-induced DNA damage in vitro by alkaline Comet assay

Background/aim: Dexmedetomidine (DEX) is an alpha-2 adrenergic agonist that is commonly used as a sedative and anesthetic. The protective effects of DEX against oxidative damage under both in vitro and in vivo conditions have been demonstrated. It was aimed to evaluate and compare the protective effects of DEX and vitamin C (Vit C) on DNA against H2O2-induced DNA damage in human lymphocyte cell cultures in vitro by alkaline Comet assay. Materials and methods: Lymphocyte cell cultures were divided into 5 groups, as the negative control, solvent control, positive control, hydrogen peroxide (H2O2; 150 µM) + DEX (1 µM; 2.5 µM; 5 µM), and H2O2 (150 µM) + Vit C (1 µM; 2.5 µM; 5 µM), and incubated at 37 °C for 1 h. Cell viability was measured using the Trypan blue test. DNA damage was measured using the Alkali Comet Technique and the % percent tail intensity was evaluated. Statistical analysis was performed using 1-way ANOVA and the Tukey multiple comparison test. Results: It was observed that H2O2 significantly induced DNA damage in the lymphocytes and this damage was decreased significantly with Vit C and DEX. It was observed that Vit C at doses of 1 µM and 2.5 µM had a significantly stronger antioxidant effect, but there was no significant difference between the antioxidant effects of Vit C and DEX with a dose of 5 µM. The dose of 5 µM DEX was found to be the most effective in reducing oxidative DNA damage. Conclusion: There is limited data on the protective effects of DEX against oxidative DNA damage. The primary effect might be cytoprotection. The results herein showed that DEX was protective against H2O2-induced in vitro oxidative DNA damage in lymphocyte cell cultures in a dose-dependent manner. DEX might have a potential therapeutic value in the prevention of oxidative DNA damage in patients.

Mortality of adult intensive care units in Turkey using the APACHE II and SOFA systems (outcome assessment in Turkish intensive care units).

INTRODUCTION: The aim of this study was to evaluate intensive care unit (ICU) performance using risk-adjusted ICU mortality rates nationally, assessing patients who died or had been discharged from the ICU. For this purpose, this study analyzed the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) databases, containing detailed clinical and physiological information and mortality of mixed critically ill patients in a medical ICU at secondary and tertiary referral ICUs in Turkey. MATERIAL AND METHODS: A total of 690 adult intensive care units in Turkey were included in the study. Among 690 ICUs evaluated, 39.7% were secondary and 60.3% were tertiary ICUs. A total of 4188 patients were enrolled in this study. Intensive care units of ministry, university, and private hospitals were evaluated all over Turkey. During the study period, clinical data that were collected concurrently for each patient contained demographic details and the diagnostic category leading to ICU admission. APACHE II and SOFA scores following ICU admission were calculated and recorded. Patients were followed up for outcome data until death or ICU discharge. RESULTS: The mean age of patients was 68.8 ±19 and 54% of them were male. The mean APACHE II score was 20 ±8.7. The ICUs' mortality rate was 46.3%, and mean predicted mortality was 37.2% for APACHE II. The standardized mortality ratio was 1.28 (95% confidence interval: 1.21-1.31). CONCLUSIONS: There was a wide difference in outcome for patients admitted to different ICUs and severity of illness using risk adjustment methods. The high mortality rate in patients could be related to comorbid diseases, high mechanical ventilation rates and older ages.

Comparison of prognostic value of N-terminal pro-brain natriuretic peptide in septic and non-septic intensive care patients.

INTRODUCTION: The aim of this study is to compare the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in septic and non-septic intensive care patients. MATERIAL AND METHODS: Fifty consecutive patients admitted to the intensive care unit (ICU) were enrolled in either the septic or non-septic group according to the criteria in the International Sepsis Definitions Conference in 2001. Demographic and clinical data, procalcitonin and lactate levels at admission, and death within 28 days were registered. Five blood samples were collected from all patients for NT-proBNP measurements. RESULTS: Septic patients had higher APACHE II (19 (16.00-24.25) vs. 16 (13.00-18.25)), and SOFA (8 (5-10) vs. 6 (4-7)) scores (p <0.05). Procalcitonin levels were also higher in septic patients (3.33 (1.06-10.96) vs. 0.46 (0.26-1.01) ng/ml) and more patients required vasopressors in this group (9 (36%) vs. 2 (8%)) (p < 0.05). In the septic group, the correlation between mortality and the level of NT-proBNP was significant for each measurement, starting from the admission. In the non-septic group the correlation between mortality and the level of NT-proBNP was significant only at the 120th h. CONCLUSIONS: We concluded that the level of NT-proBNP at admission is well correlated with 28-day mortality in septic ICU patients. However, single measurement of NT-proBNP levels in non-septic patients does not correlate with the 28-day mortality. Repeated measurements and an increasing trend of the NT-proBNP levels may show a correlation with mortality in non-septic intensive care patients.

Correlation of computed tomography, magnetic resonance imaging and clinical outcome in acute carbon monoxide poisoning / Correlação de tomografia computadorizada, ressonância magnética e resultados clínicos em intoxicação aguda por monóxido de carbono

Abstract Background and objectives: Carbon monoxide is a toxic gas for humans and is still a silent killer in both developed and developing countries. The aim of this case series was to evaluate early radiological images as a predictor of subsequent neuropsychological sequelae, following carbon monoxide poisoning. Case 1: After carbon monoxide exposure, early computed tomography scans and magnetic resonance imaging findings of a 52-year-old woman showed bilateral lesions in the globus pallidus. This patient was discharged and followed for 90 days. The patient recovered without any neurological sequela. Case 2: In a 58-year-old woman exposed to carbon monoxide, computed tomography showed lesions in bilateral globus pallidus and periventricular white matter. Early magnetic resonance imaging revealed changes similar to that like in early tomography images. The patient recovered and was discharged from hospital. On the 27th day of exposure, the patient developed disorientation and memory impairment. Late magnetic resonance imaging showed diffuse hyperintensity in the cerebral white matter. Conclusion: White matter lesions which progress to demyelination and end up in neuropsychological sequelae cannot always be diagnosed by early computed tomography and magnetic resonance imaging in carbon monoxide poisoning.

Resumo Justificativa e objetivos: Monóxido de carbono é um gás tóxico para os seres humanos, além de ser um assassino silencioso tanto em países desenvolvidos quanto em desenvolvimento. O objetivo desta série de casos foi avaliar as imagens radiológicas iniciais como um preditivo de sequelas neuropsicológicas decorrentes de intoxicação por monóxido de carbono. Caso 1: Após exposição ao monóxido de carbono, os achados iniciais em tomografias computadorizadas e ressonâncias magnéticas de uma mulher de 52 anos mostraram lesões em globo pálido bilateralmente. A paciente recebeu alta e foi acompanhada por 90 dias. Recuperou-se sem sequelas neurológicas. Caso 2: Paciente do sexo feminino, 58 anos, exposta ao monóxido de carbono. A tomografia computadorizada mostrou lesões em globo pálido, bilateralmente, e substância branca periventricular. A ressonância magnética inicial revelou alterações semelhantes àquelas em tomografias precoces. A paciente se recuperou e recebeu alta. No 27° dia de exposição, evoluiu com desorientação e perda de memória. Ressonância magnética posterior mostrou hiperintensidade difusa da substância branca cerebral. Conclusão: As lesões da substância branca que progridem para desmielinização e resultam em sequelas neuropsicológicas nem sempre podem ser diagnosticadas em tomografias e ressonâncias iniciais em casos de intoxicação por monóxido de carbono.

Correlation of computed tomography, magnetic resonance imaging and clinical outcome in acute carbon monoxide poisoning.

BACKGROUND AND OBJECTIVES: Carbon monoxide is a toxic gas for humans and is still a silent killer in both developed and developing countries. The aim of this case series was to evaluate early radiological images as a predictor of subsequent neuropsychological sequelae, following carbon monoxide poisoning. CASE 1: After carbon monoxide exposure, early computed tomography scans and magnetic resonance imaging findings of a 52-year-old woman showed bilateral lesions in the globus pallidus. This patient was discharged and followed for 90 days. The patient recovered without any neurological sequela. CASE 2: In a 58-year-old woman exposed to carbon monoxide, computed tomography showed lesions in bilateral globus pallidus and periventricular white matter. Early magnetic resonance imaging revealed changes similar to that like in early tomography images. The patient recovered and was discharged from hospital. On the 27th day of exposure, the patient developed disorientation and memory impairment. Late magnetic resonance imaging showed diffuse hyperintensity in the cerebral white matter. CONCLUSION: White matter lesions which progress to demyelination and end up in neuropsychological sequelae cannot always be diagnosed by early computed tomography and magnetic resonance imaging in carbon monoxide poisoning.

The Relationship Between Glutathione S-Transferase-P1 and Beta-2 Adrenoreceptor Genotypes with Asthmatic Patients in the Turkish Population.

BACKGROUND: Individual differences in the activity of enzymes that metabolize xenobiotics can impact health and disease. Beta-2 adrenoreceptor (ADRB2) is a functional G-coupled protein expressed in the vascular endothelium of lungs, alveolar walls, and the ganglions of cholinergic nerves which induces bronchodilation in response to catecholamines. Glutathione S-Transferase-P1 (GSTP1) is a candidate pi class GST gene, which controls pi class glutathione S-transferase activity. AIMS: In this study we determined the relationship between the ADRB2 Arg16Gly polymorphism and GSTP1 polymorphisms, involved in bronchodilator response and oxidative stress, respectively, with susceptibility to asthma. METHODS: In this study, 129 asthmatic patients and 127 healthy control cases were recruited to determine ADRB2 and GSTP1 genotypes by allele-specific polymerase chain reaction and restriction fragment length polymorphism assays, respectively. RESULTS: The ADRB2 genotype frequencies of the patients and control cases were found to be 10.9% (Arg16Arg), 48.8% (Arg16Gly), and 40.3% (Gly16Gly) and 24.4% (Arg16Arg), 36.2% (Arg16Gly), and 39.4% (Gly16Gly), respectively. GSTP1 genotype frequencies of patients and control cases were found to be 55% (Ile105Ile), 43.4% (Ile105Val), and 1.6% (Val105Val) and 75.6% (Ile105Ile), 22% (Ile105Val), and 2.4% (Val105Val), respectively. In the case of the GSTP1 gene, we found statistically significant differences in the genotype frequency of Ile105Val and the allele frequency of Val105 in the asthmatic group compared with the controls. Moreover, we observed a relationship between allele frequencies and clinical phenotypes including atopia nocturnal dyspnea, and steroid dependency in the asthmatic patients. CONCLUSION: Our results suggest that the GSTP1 Ile105Val polymorphism may be linked to the severeness of airway dysfunction.

Enoxaparin effect on malondialdehyde levels in laparoscopic cholecystectomy.

INTRODUCTION: This study was established to assess the effects of low dose enoxaparin on plasma malondialdehyde levels during laparoscopic cholecystectomy as a model of ischemia-reperfusion. MATERIALS AND METHODS: Fifty patients, scheduled for laparoscopic cholecystectomy, were randomized into two groups of 25 patients in each. In enoxaparin group, patients had 20 mg/0.2 ml subcutaneous (sc) enoxaparin 2 hr before surgery. Blood samples were obtained for malondialdehyde, alanine transferase, aspartate transferase, measurements before the insufflation, 1 min before deflation, and 20 min after deflation. RESULTS: Plasma malondialdehyde concentrations were insignificant between enoxaparin and control groups before insufflation (1.64 ± 2.66 vs. 2.45 ± 4.42 µmol l(-1); p = 0.44) and 1 min before deflation (1.55 ± 2.61 vs. 3.66 ± 5.68 µmol l(-1); p = 0.38). Malondialdehyde levels significantly increased in control group 20 min after deflation in respect to enoxaparin group (1.52 ± 2.67 vs. 6.04 ± 7.85 µmol l(-1)), (p = 0.049). In control group, plasma malondialdehyde concentrations increased significantly compared with initial level throughout the study (p = 0.001). Within enoxaparin group, no statistically significant change was observed (p = 0.28). Plasma alanine transferase and aspartate transferase levels increased similarly in both groups during the study (p > 0.05). Alanine transferase and aspartate transferase increases within each group were statistically significant for all times (p < 0.05). DISCUSSION AND CONCLUSIONS: As a conclusion, mini dose of enoxaparin used sc'ly 2 hr before the operation, prevented the malondialdehyde increase during reperfusion period after laparoscopic cholecystectomy without causing any bleeding disorder while having no effect on serum alanine transferase, aspartate transferase increase.

Treatment of post-dural puncture headache with bilateral greater occipital nerve block.

(Headache 2010;50:869-881) Epidural blood patch is an effective treatment with a low complication rate. It is also an invasive method that can cause permanent neurological sequelae such as early and late back pain, radiculopathy, spinal-subdural hematoma, spinal-epiarachnoid hematoma, intrathecal hematoma, arachnoiditis, and infection. We report a case in which a postdural puncture headache resolved within 2 minutes of a greater occipital nerve block, a minimally invasive and easy procedure with a low complication rate. This case report suggests that a greater occipital nerve block may be a successful alternative treatment for patients with post-dural puncture headache.

The effects of preanesthetic, single-dose dexmedetomidine on induction, hemodynamic, and cardiovascular parameters.

STUDY OBJECTIVES: To investigate the hemodynamic, cardiovascular, and recovery effects of dexmedetomidine used as a single preanesthetic dose. DESIGN: Randomized, prospective, double-blind study. SETTING: University Hospital of Kirikkale, Kirikkale, Turkey. PATIENTS: 40 ASA physical status I and II patients, aged 20 to 60 years, who were scheduled for elective cholecystectomy. INTERVENTIONS: Patients were randomly divided into two groups to receive 0.5 microg kg(-1) dexmedetomidine (group D, n = 20) or saline solution (group C, n = 20). Anesthesia was induced with thiopental sodium and vecuronium, and anesthesia was maintained with 4% to 6% desflurane. MEASUREMENTS: Mean arterial pressure (MAP), heart rate (HR), ejection fraction (EF), end-diastolic index (EDI), cardiac index (CI), and stroke volume index (SVI) were recorded at 10-minute intervals. The times for patients to "open eyes on verbal command" and postoperative Aldrete recovery scores were also recorded. MAIN RESULTS: In group C, an increase in HR and MAP occurred after endotracheal intubation. In group D, HR significantly decreased after dexmedetomidine was given. The EDI, CI, SVI, and EF values were similar in groups D and C. The modified Aldrete recovery scores of patients in the recovery room were similar in groups C and D at the 15th minute. CONCLUSIONS: A single dose of dexmedetomidine given before induction of anesthesia decreased thiopental requirements without serious hemodynamic effects or any effect on recovery time.

The preoperative analgesic effect of 3-in-1 block on postoperative pain and tramadol consumption in total hip arthroplasty.

We studied the effect of preoperative 3-in-1 block for total hip replacement surgery on postoperative pain and tramadol consumption during patient-controlled analgesia. Thirty ASA I-II patients undergoing elective total hip arthroplasty (THA) were included in the study. Patients were randomly divided into 2 groups; Group I: Patients who received 3-in-1 block with 40 ml of 0.25% bupivacaine 30-minutes before surgery and later received general anesthesia, Group II: Patients who received only a simple needle puncture at the operation site 30-minutes before surgery and later received general anesthesia. All patients received intravenous tramadol at the end of surgery via a PCA device. Pain was evaluated at 0,1/2,1,4,8,12,24 and 48 h at rest and on movement of the hip, using a 10 cm VAS. The average intraoperative fentanyl consumption was lower in Group I than in Group II. VAS scores were significantly lower in group I, both at rest and during movement at all timepoints over in the first postoperative 12 h and also during movement 24 h postoperatively. However differences in VAS scores weren't clinically significant after 4 hours. In the recovery room, Group I VAS scores were only a third of Group II, both at rest and movement (p=0.0001). Total tramadol consumption was lower in Group I (633.0+/-119.3 mg) than in Group II (991.1+/-41.0 mg). Patient satisfaction scores were higher in Group I than in Group II. We concluded that preoperative 3-in-1 block with 40 ml-0,25% bupivacaine provides effective postoperative pain relief for elective THA, reducing intra-and postoperative analgesic consumption without increase in side effects.

[Effect of preoperative 900 and 1200 mg single oral dose of gabapentin on postoperative pain relief and tramadol consumption in open cholecystectomy surgery]. / Açik kolesistektomi cerrahisinde preoperatif tek doz oral 900 ve 1200 mg gabapentinin postoperatif agri ve tramadol tüketimi üzerine etkisi.

In this study, the effects of preoperative 900 and 1200 mg single dose of gabapentin on postoperative pain relief and tramadol consumption in elective open cholecystectomies were investigated. Fourty-five ASA I-II patients were randomly divided into three groups. Group I was control group and patients in group II and III received 900 mg or 1200 mg gabapentin 1 hour before the operations respectively. All patients received intravenous tramadol at the end of surgery via a patient controlled analgesia (PCA) device. Pain scores were evaluated at the recovery room (0),1, 2, 3, 4, 6, 8, 12 and 24h postoperatively at rest and movement, using a 10 cm VAS. In the recovery room, VAS scores at rest were three times less (1,4+/-0.6 versus 4,9+/-1.0 and 4.4+/-1.1), and visual analogue scale (VAS) scores at movement were two times less (3.4+/-1.0 versus 6.8+/-1.8 ve 6.1+/-1.6) in group III when compared to group I and II respectively. Mean loading doses were significantly lower in group III (28.3+/-8.7) than group I (66.6+/-20.4) and II (61.6+/-20.8). VAS scores at rest during the postoperative first 6h and at movement during the postoperative first 8h were significantly lower in group III than group I and II. Total tramadol consumption was lower in group III (240.4+/-31.0), than group I (456.0+/-35.5) and group II (438.7+/-35.0). Additional meperidine was necessary for two patients both in groups I and II, although none of the patients needed in group III. Higher patient satisfaction scores were obtained in group III. Adverse effect incidences were higher in group I and II than in group III. As a result, we believe that to improve analgesic quality after open cholecystectomy, preoperative single dose of gabapentin should at least be 1200 mg.

Use of the NMDA antagonist magnesium sulfate during monitored anesthesia care for shockwave lithotripsy.

PURPOSE: To assess whether intravenous magnesium sulfate infusion affects analgesic requirements during monitored anesthesia care (MAC) for shockwave lithotripsy (SWL). PATIENTS AND METHODS: Fifty patients in ASA class I or II undergoing SWL with MAC were randomized into two groups. Induction of MAC was produced by bolus doses of midazolam 0.03 mg/kg(-1) and fentanyl 0.5 microg/kg(-1) followed by intravenous infusion of midazolam 0.015 to 0.06 mg/kg(-1)/hr(-1) with fentanyl supplementation 0.2 microg/kg(-1). In addition, group I patients received magnesium sulfate 30 mg/kg(-1) intravenously as a bolus dose followed by a continuous infusion of 10 mg/kg(-1) /hr(-1) beginning 15 minutes before induction of sedation. The midazolam infusion rate and additional fentanyl doses were adjusted by verbal analog scale (VAS) measurements, observer assessment sedation score (OAA/S), and achieving a target bispectral index (BIS) in a range of 70 to 90. At the end of SWL, the total midazolam and total fentanyl consumptions were recorded, and the serum magnesium concentration was measured. RESULTS: Magnesium caused significant decreases in the total consumption of midazolam (P = 0.001) and fentanyl (P = 0.001). The VAS values at the 15th, 20th, and 25th minute in group I were significantly lower than in group II. In group I, hemodynamic and arterial oxygen parameters were better than in group II. CONCLUSION: A magnesium bolus and infusion can be utilized to reduce analgesic requirements under MAC during SWL.

beta2 adrenoceptor (ADRB2) pharmacogenetics and cardiovascular phenotypes during laryngoscopy and tracheal intubation.

Pharmacogenetics is the study of genetic variations that cause a variable drug response characterized by alteration in drug metabolism or in pharmacodynamics. The polymorphisms in genes encoding receptors relevant to treatment cause variation in sensitivity to many drugs. beta2 Adrenoceptor genetic variation contributes to regulation of blood pressure and hemodynamic changes by mediating peripheral vasodilatation. Laryngoscopy and tracheal intubation associated with hemodynamic changes. Although there are four nonsynomic single-nucleotide polymorphisms (SNPs) of beta2 adrenoceptor gene, codon 16 (Arg16Gly) and codon 27 (Gln27Glu) SNPs are both common and functionally important. In this paper, the authors investigated the beta2 adrenoceptor Gly16 and Glu27 SNPs in response to drugs relevant to anesthesia and how these SNPs impacted upon the cardiovascular phenotypes. The authors measured arterial systolic and diastolic blood pressure, heart rate, and rate-pressure product before induction of anesthesia and 1 min following laryngoscopy and tracheal intubation. Genomic DNA was amplified and genotyped using allele-specific polymerase chain reaction (ASPCR) and restriction fragment length polymorphism (RFLP) assays, respectively. When the authors compared hemodynamic results according to genotypes, the patients with Gln homozygote allele at codon 27 exhibited significant increase of heart rate than patients with Glu allele after laryngoscope and tracheal intubation.

Ketamine combined with morphine for the management of cancer pain in a patient with meperidine tolerance and addiction.

Pain treatment of patients with opioid addiction and tolerance may be challenging due to their unexpectedly higher pain sensitivities and opioid requirements. It has been reported that the N-methyl-D-aspartate receptor is involved in mechanisms of tolerance to opioid analgesics. Recently enhancement of morphine induced analgesia by low dose ketamine addition to the treatment regimen has been reported. We report a cancer patient with meperidine tolerance and psychological dependency to the agent who was afterwards successfully treated with morphine-ketamine combination.

Genoprotective role of vitamin E and selenium in rabbits anaesthetized with sevoflurane.

In this study, genotoxic effects of repeated sevoflurane anaesthesia were investigated in rabbits with or without antioxidant supplementation. Twenty-one New Zealand male rabbits were included in the study and randomized into three groups as: placebo treated (Group I), vitamin E supplemented (Group II) and selenium supplemented (Group III). Vitamin E and selenium were given intraperitoneally for 15 days before anaesthesia treatment. Anaesthesia was administered using 3% sevoflurane in 4 L/min oxygen for a 3-hour period and continued for 3 days. Blood samples were collected before anaesthesia (Sample 1), after the first, second and third days of sevoflurane administration (Sample 2, Sample 3 and Sample 4 respectively) and the last samples were taken 5 days after the last sevoflurane administration (Sample 5). Genotoxic damage was examined using the comet assay. The degree of damage is assessed by grading the cells into three categories of no migration (NM), low migration (LM) and high migration (HM) depending on the fraction of DNA pulled out into the tail under the influence of the electric field. The number of comets in each sample was calculated (1 x number of comets in category NM+2 x number of comets in category LM+3 x number of comets in category HM) and expressed as the total comet score (TCS), which summarizes the damage frequencies. In Group I, a significant increase in the mean TCSs was observed for Samples 3 and 4 as compared with Sample 1. However, there were no significant differences between Samples 1, 2 and 5. The mean TCS of Sample 4 was significantly higher than Sample 1, 2 and 3 in Group II. Group III demonstrated no significant mean TCSs for any experimental conditions. Statistical differences were also observed between the groups with significant P values. This experimental study points out the presence of DNA damage with repeated sevoflurane anaesthesia and the genoprotective role of antioxidant supplementation on DNA damage in mononuclear leukocytes of rabbits by highly sensitive comet assay.