Using "Shadow Board" in Spinal Anesthesia Preparation: A Lean Healthcare Practice.

To the editor: The 21st century is proving to be a very important period in healthcare services with the widespread use of quality improvement programs.

Current Approaches in Hip and Knee Arthroplasty Anaesthesia.

Risk assesment, preoperative drug regulation, the anesthesia and analgesia techniques are very important and the effectivity on success of surgery is great. So, these topics in arthroplasty were reviewed under current knowledge.

Preperitoneal catheter analgesia is an effective method for pain management after colorectal surgery: the results of 100 consecutive patients.

BACKGROUND: In a previous prospective randomized trial, we showed that local anesthetic infusion using a preperitoneal catheter is an effective postoperative analgesic method following colorectal resections. Over time, we have improved the technique of preperitoneal catheter analgesia. In this prospective cohort study, we report the results of 100 consecutive patients who underwent colorectal resections. MATERIALS AND METHODS: Preperitoneal catheter analgesia was performed via a multihole catheter placed in the preperitoneal space using 10 mL 0.5% levobupivacaine every 4 hours following the operation for the first 3 days. Additional analgesics were used whenever necessary. Postoperative pain was assessed with the visual analog scale score. Short-term clinical outcomes, such as need for systemic analgesics, time to first gas and stool discharge, length of hospital stay, and morbidity, particularly surgical site infections, were reported. RESULTS: From May 2009 to May 2010, 100 consecutive patients were recruited in the study. A total of 83 patients were operated on for malignancy, and the tumor was located in the rectum in 52 patients and in the colon in 31 patients. The median pain score was 4 (0-6), 3 (0-9), 2 (0-8), 1 (0-8), 1 (0-6), 0 (0-6), and 0 (0-3) at postoperative hours 0, 1, 4, 12, 24, 48, and 72, respectively. Additional analgesics were required in 34 patients: 21 of them required only nonsteroidal anti-inflammatory drugs, and 13 patients needed opioids additionally. The median amounts of opioid analgesics and nonsteroidal anti-inflammatory drugs were 1.76±0.78 mg and 6.70±1.18 mg, respectively. However, almost all of the additional analgesics were given in the first 24 hours. Surgical site infections were detected in eight patients. CONCLUSION: Preperitoneal catheter analgesia is an effective analgesic method. When applied and used properly, it may even be used as the sole analgesic method in some patients.

Association between self reported snoring, STOP questionnaire and postoperative pulmonary complications in patients submitted to ortophaedic surgery.

BACKGROUND: Obstructive sleep apnea (OSA) may increase perioperative complications. The aim of this study was to determine the relationship among postoperative pulmonary complication, snoring and STOP questionnaire in patients with ortophaedic surgery. METHODS: 1,406 consecutive records of patients who had undergone elective ortophaedic surgery during the period January 2005-December 2008 were investigated retrospectively. Demographic information, sleep symptoms, STOP questionnaire, comorbidities and outcome data were collected. RESULTS: There were 289 (20.5%) snorers and 1,117 (79.5%) non-snorers in the study group. There was no significant difference between snorer and non-snorer patients (p > 0.05) in the prevalence of pneumonia and respiratory failure. But in snorer patients the rate of postoperative atelectasis was significantly higher than in non-snorer group (p < 0.0001). The STOP Questionnaire was given to 1,406 patients and 147 (10.4%) out of them were classified at high risk of OSA. There was no significant difference in the prevalence of pneumonia and respiratory failure between low and high risk group (p > 0.05). However, in high risk patients the occurrence of postoperative atelectasis was significantly higher than in low risk group (p < 0.0001). CONCLUSION: Postoperative atelectasis was significantly more prevalent in the high risk group according to STOP questionnaire.

Comparison of intraarticular bupivacaine and levobupivacaine with morphine and epinephrine for knee arthroscopy.

OBJECTIVE: To compare the efficacy of intraarticularly injected bupivacaine with levobupivacaine when administered in combination with morphine and adrenaline for post-operative analgesia and functional recovery after knee surgery. MATERIALS AND METHODS: Sixty American Society of Anesthesiologists physical status I-II patients were randomized into three groups: Group B was administered 30 mL isobaric 0.5% bupivacaine, 2 mg morphine and 100 µg adrenaline, Group L was administered 30 mL 0.5% levobupivacaine, 2 mg morphine and 100 µg adrenaline, and Group C was administered 30 mL 0.9% NaCl solution into the knee joint by the surgeon at the end of surgery. The morphine usage and visual analog pain scores were recorded regularly afterwards. We also recorded the time that elapsed before each patients' first mobilization, positive response to straight leg raising, tolerance to 30-50° knee flexion, recovery of quadriceps reflexes and discharge from the hospital. We also recorded patient and surgeon satisfaction. RESULTS: The pain scale values were lower in Groups B and L than in Group C at 2, 4, 6, 8, 12 and 24 hours post-operatively (all p<0.001). In Groups B and L, the time for first analgesic request was longer (p<0.01), the morphine consumption was lower (p<0.001), and the duration of morphine usage was shorter (p<0.001). The times to positive response to straight leg raising, tolerance to 30-50° knee flexion and the first mobilization were shorter in Groups B and L (p<0.001 for all). CONCLUSION: After arthroscopic knee surgery, intraarticular levobupivacaine combined with morphine and adrenaline decreases analgesic requirements, shortens the postoperative duration of analgesic use and hastens mobilization as effectively as bupivacaine.

Ogilvie's syndrome following bilateral knee arthroplasty: a case report.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction, is an uncommon but severe postoperative complication of total hip and knee arthroplasty. This syndrome should be borne in mind after arthroplasty surgery. We present a case of this serious postoperative complication and aim to identify the risk factors and alert surgeons to the possibility and appropriate management of Ogilvie's syndrome.

Functional results of conservative therapy accompanied by interscalane brachial plexus block and patient-controlled analgesia in cases with frozen shoulder.

OBJECTIVES: We evaluated the efficacy of simultaneous interscalene block and catheter analgesia applied as an aid to conservative treatment in improving shoulder functions in patients with frozen shoulder. METHODS: Three patients (2 women, 1 man; mean age 47 years) with frozen shoulder underwent conservative treatment including manipulation under interscalene brachial plexus block and subsequent rehabilitation under catheter analgesia to improve shoulder range of motion and function. Following manipulation under interscalene block, the patients were hospitalized for 15 to 28 days (mean 21 days) for an exercise program performed by a physiotherapist and orthopedist at least twice a day under interscalene catheter analgesia. Thirty minutes before each rehabilitation session, patient-controlled analgesia was administered via a pain relief pump. Active and passive range of motion (ROM) were measured and the severity of pain was rated using a visual analog scale (VAS) prior to and following interscalene block, during the exercise program, and at the end of the treatment. Functional assessments were made before and after treatment using the University of California in Los Angeles (UCLA) Shoulder Scale. The exercise program under interscalene analgesia was performed until pain-free and sufficient active movements were obtained, with at least 80% improvement in active and passive motion, a VAS score of 0-2, and an UCLA score of >27. RESULTS: Compared to pretreatment values, the ROM values showed remarkable increases at the end of the treatment. Active ROM reached at least 30 degrees external rotation, 40 degrees internal rotation, 150 degrees flexion, 45 degrees extension, and 100 degrees abduction in all cases. On presentation, the VAS scores of all cases were 10 for both active and passive movements, whereas they ranged from 0 to 2 on discharge. The mean UCLA score increased from 12.3 to 30.3 after treatment. Immediately after the interscalene block, two patients exhibited signs of Horner's syndrome which resolved spontaneously within an hour without the need for treatment. No complications or catheter-related problems such as infection, break-off, or displacement developed throughout the treatment period. There was no requirement for additional analgesia. CONCLUSION: In patients with frozen shoulder, interscalene block and continuous patient-controlled analgesia via an interscalene catheter provided sufficient analgesia and contributed to the recovery of shoulder functions through an effective and safe exercise program, with no side effects or complications. However, further studies are needed to assess the feasibility of home applications of interscalene patient-controlled analgesia to increase cost-effectiveness and patient satisfaction.

Anti-inflammatory efficiency of levobupivacaine in an experimental colitis model.

AIM: To investigate the efficiency of levobupivacaine in treating experimentally induced colitis in rats. METHODS: Colitis was induced by trinitrobenzene sulfonic acid and ethanol in 30 rats under general anesthesia, and 10 rats were used as a sham group. Subsequent to induction of colitis, rats were divided into three groups; budesonide group received 0.1 mg/kg budesonide, levobupivacaine group received 10 mg/kg levobupivacaine and saline group received 1 mL saline solution via rectal route for 7 d. In the sham group, only routine rectal catheterization was performed without use of any material. At the end of 7 d, laparotomy and total colectomy were performed for histopathological examination in all rats and blood samples were drawn for measurement of tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 following cardiac puncture. Macroscopic and microscopic evaluations of the specimens were performed by a pathologist blinded to group assignment of the rats. RESULTS: Weight loss (P = 0.016) and macroscopic examination scores (P = 0.001) were significantly higher in saline group than others. Histopathological scoring was comparable between all colitis groups (P = 0.350). There was no significant difference in TNF-alpha levels and IL-6 levels (P = 0.150). CONCLUSION: The significant improvement in macroscopic scores suggests that levobupivacaine may have topical anti-inflammatory effects in an experimental colitis model; however, this finding was not supported by microscopic findings.

[Comparing the effects of analgesia techniques with controlled intravenous and epidural on postoperative pain and knee rehabilitation after total knee arthroplasty]. / Total diz artroplastisi sonrasi intravenöz ve epidural hasta kontrollü analjezi tekniklerinin ameliyat sonrasi agri ve diz rehabilitasyonu üzerine etkilerinin karsilastirilmasi.

OBJECTIVES: We aimed to compare the effects of controlled intravenous (iv.) and epidural analgesia techniques on postoperative analgesia and knee rehabilitation after total knee arthroplasty (TKA). PATIENTS AND METHODS: After the approval of the ethical committee, both i.v. (group I.V; n=20) and epidural (group E; n=22) postoperative analgesia (PCA) were applied in 42 patients (range 18 to 75 years) undergoing TKA. Because of dislocation of epidural catheters in the postoperative period, two cases were excluded from the study and 20 patients in each group were evaluated. Postoperative pain was assessed with the visual analog scale (VAS) and it was recorded in the recovery unite and then at the 4th, 8th, 12th, 16th, 24th, 48th and 72nd hours. The knee flexion angles of patients were daily measured with a goniometer. The data were analyzed using Mann Whitney U-test, two-samples independent t-test, Fisher exact-chi squared and Pierson chi squared tests. RESULTS: Demographic variables were similar in two groups. In group E, VAS scores at rest and motion were found to be significantly lower and knee flexion angles were significantly higher than that of the group I.V. CONCLUSION: We determined that epidural PCA provided better pain relief and rehabilitation than iv. PCA in postoperative period after TKA.

Does single, low-dose preoperative dexamethasone improve outcomes after colorectal surgery based on an enhanced recovery protocol? Double-blind, randomized clinical trial.

Preoperative single, high-dose methylprednisolone administration improves postoperative outcomes after colonic surgery. Several randomized studies, including major surgeries, assessed various high-dose steroid regimens; however, evidence about the effect of administration of lower doses on postoperative outcomes in colorectal surgery is not available. The aim of the present study is to determine whether the administration of a single, low dose of dexamethasone before surgery would confer an outcome advantage after colorectal surgery. Thirty patients undergoing colorectal surgery were included in this randomized, double-blind study. Patients received 8 mg dexamethasone or serum physiologic preoperatively. Levels of Interleukin-6 and C-reactive protein, pain scores, postoperative nausea and vomiting, mobilization, complications, hospital stay, and readmissions were compared. Age, sex, indications, and operations were similar in both groups (P > 0.05). C-reactive protein and Interleukin-6 levels increased significantly postoperatively in each group (P < 0.05), but there were no differences between groups when compared (P > 0.05). There were also no significant differences between pain scores, bowel functions, mobilization, hospital stay, complication rates, and readmission rates between the two groups (P > 0.05). Preoperative 8 mg dexamethasone administration has no significant effect on reducing postoperative inflammatory response and also does not improve outcomes of colorectal surgery.

Criteria to consider when assessing the mortality risk in geriatric surgery.

As the population ages, surgery is performed more frequently on geriatric patients for both elective and emergency situations. Four hundred sixty-nine patients > or = 70 years of age who underwent operations were retrospectively reviewed. Sex, American Society of Anesthesiologists (ASA) score, type of admission, main surgical diagnosis, benign or malignant nature, site of disease, concomitant disease, preoperative ASA grade, and death were assessed. The ratio of the elderly against all those who were operated on in our department during the same period was 5.9%. The mortality rate was 8.5% for men and 9.4% for women. According to ASA scoring, mortality rates were 0%, 8.8%, 29.8%, 36.8%, and 66.6%, respectively (P < 0.05). The mortality rate was 2.5% for elective and 49.2% for emergency procedures (P < 0.0001). The mortality rate was 9.7% for benign and 7.2% for malignancy. Hepatopancreatic biliary conditions were most common (39.6%), followed by colorectal (19.4%), hernia (18.8%), upper gastrointestinal (15.3%), and endocrine disease (6.9%). The highest mortality rate was for diseases of the upper gastrointestinal system (30.5%; P < 0.001). The incidence of associated disease was 13.1% in patients who died (P < 0.005). Overall mortality rate in this study was 8.9%. In emergency surgery, the presence of associated disease, an ASA score of III-V, and upper gastrointestinal surgery affected the risk of postoperative death in elderly patients.

Comparison of ilioinguinal-iliohypogastric nerve block versus spinal anesthesia for inguinal herniorrhaphy.

OBJECTIVE: This study was carried out to determine the optimal anesthetic technique for use in elective herniorrhaphy. METHODS: We retrospectively analyzed 126 inguinal hernia repairs. The patients were allocated to one of two groups: an ilioinguinal-iliohypogastric nerve block group (IHNB group, n = 63) and spinal anesthesia group (SA group, n = 63). We recorded information about perioperative and postoperative parameters. RESULTS: There were statistically significant decreases in both mean arterial pressure and pulse rate in the SA group (P < 0.001). None of the patients in the IHNB group required recovery room care. Patients in the IHNB group initiated oral intake (0.31 +/- 0.1 h) more quickly than patients in the SA group (5.74 +/- 0.1 h) (P < 0.001). The time-to-home readiness was significantly lower (14.1 +/- 1.5h) in group IHNB, compared with group SA (42.8 +/- 5.3h) (P < 0.001). First rescue analgesic time postoperatively was 3.30 +/- 0.2 hours in group SA and 2.7 +/- 0.13 hours in group IHNB (P < 0.05). CONCLUSION: The use of IHNB for patients undergoing herniorrhaphy resulted in a shorter time-to-home readiness, quicker oral intake post surgery, and no need for recovery room care, when compared with the use of SA.