What is the optimal dose of intrathecal meperidine in open prostate surgery? A prospective double-blind randomized study.

OBJECTIVES: This study was an analysis of the effect of different dosages of intrathecal meperidine (40 mg, 50 mg, 60 mg, and 70 mg) on hemodynamic parameters, the duration of neural blockade, and the incidence of meperidine-related side effects in patients who underwent an open prostatectomy. METHODS: Sixty patients who underwent an open prostatectomy with combined spinal-epidural anesthesia were included. The patients were allocated to receive 1 of 4 different dosages of intrathecal meperidine (n=15 for each group): Group I: 40 mg, Group II: 50 mg, Group III: 60 mg, and Group IV: 70 mg. The duration of the block procedure, surgery duration, highest sensory block level, and anesthetic complications were recorded and analyzed. RESULTS: At 20 minutes after the spinal injection, the maximum sensory block level was T6 in Group I and II, and it was T5 in Group III and IV. The mean motor block scores at 20 minutes after the spinal injection were lower in Group I compared with the other groups (p<0.001 for all). The motor block duration was significantly shorter in Group I and II than in Group III and IV (p<0.001 for all). Surgeon satisfaction was greater in Group II, III, and IV compared with Group I (p<0.001 for all). Patient satisfaction was better in Group III and IV compared with Groups I and II (p<0.001 for all). CONCLUSION: Intrathecal meperidine at a dose of 60 mg exerted a sufficient analgesic effect with minimum side effects in patients undergoing open prostatectomy.

[Preemptive analgesic efficacy of gabapentin and nimesulide in the functional endoscopic sinus surgery]. / Fonksiyonel endoskopik sinüs cerrahisinde gabapentin ve nimesulidin preemptif analjezik etkinligi.

OBJECTIVES: Preemptive analgesia is an important factor in controlling the postoperative pain and avoiding the stress response caused by the surgery. We aim to compare impact of gabapentin and nimesulide on postoperative analgesic consumption on the visual analog scale (VAS) as well as any potential side effects, to those of the placebo group. METHODS: Ninety patients aged 18-70 under ASA I-II risk, who were to undergo Functional Endoscopic Sinus Surgery (FESS), were included in the study. Patients were randomized into three groups. One hour before the surgery, oral placebo capsules were administered to Group I patients, Gabapentin 1200 mg to Group II patients and Nimesulide 100 mg to Group III patients. Perioperative hemodynamic parameters were measured for all patients. During the first 24 hours of the postoperative period, side effects such as nausea, vomiting, hypotension, hypertension, bradycardia, tachycardia were noted, and the time from end of the surgery to the first diclofenac need was recorded in addition to VAS scores. RESULTS: In all of the follow-ups for 24 hours of the postoperative period, time from end of the surgery until the first diclofenac requirement; Group 2 > Group 3 > Group 1. Total diclofenac consumption of group 2 was found to be significantly lower than Group 1 and Group 3 on a statistical basis. Postoperative VAS score in Group 2 was lower than Group 1 and Group 3. CONCLUSION: To conclude, we believe that gabapentin or nimesulide may be safely used preemptively for the purposes of postoperative analgesia after FESS procedures.

GlideScope video laryngoscopy use tracheal intubation in patients with ankylosing spondylitis: a series of four cases and literature review.

Airway management in patients with ankylosing spondylitis (AS) is a challenging problem for anesthesiologists. The GlideScope video laryngoscope (GVL) is designed to assist tracheal intubation for patients with a difficult airway. The aim of the study was to report the successful intubation by GVL of four AS patients, and to discuss the use of GVL for tracheal intubation in patients with AS by performing a review of the literature. Four patients with chronic, severe AS were evaluated preoperatively; all had features associated with a difficult direct laryngoscopy. We performed the necessary preparations for difficult airway and intubation. Patients were kept in supine position, with their head and neck supported on pillows. Following sufficient preoxygenation, patients received i.v. remifentanil at 1 µg kg(-1), propofol at 2 mg kg(-1), and succinylcholine at 1 mg kg(-1). GVL intubation was provided after full muscle relaxation. GVL is reasonable alternative to awake fiberoptic bronchoscopy or any other device, as it appears that less training and skill is involved in the actual intubation process. Adequate laryngeal exposure was obtained in all patients were successfully intubated in the first attempt. As with any challenging airway management, it is essential to have a rescue strategy. We believe that GVL can be a good alternative for oral endotracheal intubation in patients with AS. This series is very small and the reader should be very cautious about drawing broad conclusions regarding the GVL and patients with AS.

Glidescope Video Laryngoscope Use for Tracheal Intubation in a Patient with CHARGE Syndrome.

CHARGE syndrome is an autosomal dominant syndrome in which ocular coloboma (C), heart defects (H), choanal atresia (A), growth retardation (R), genital hypoplasia (G), ear abnormalities (E), and tracheoesophageal fistula, dysphagia, cleft palate, micrognathia, facial paralysis, hypopituitarism, and brain abnormalities may be seen in patients. The patients with CHARGE syndrome face surgical procedures many times from birth. Especially, the problems we meet in the airway may be special. In this case report, we aimed to share our experience of endotracheal intubation performed with Glidescope video laryngoscopy for a patient at the age of 20 months, weight 7.5 kg and height 70 cm, with CHARGE syndrome who was undergoing cochlear implantation.

Ultrasound-guided infraclavicular brachial plexus block enhances postoperative blood flow in arteriovenous fistulas.

OBJECTIVE: Brachial plexus block offers several advantages when creating vascular access for hemodialysis. However, no controlled studies have directly evaluated arteriovenous fistula (AVF) blood flow in patients anesthetized by this method. We compared the effects of ultrasound-guided, infraclavicular brachial plexus block and local infiltration anesthesia on blood flow in the radial artery and AVF during the early and late postoperative periods. METHODS: Sixty patients were randomly assigned to an experimental group, which received infraclavicular brachial plexus block (IB), or to a control (C) group that received local infiltration anesthesia. Blood flow in the distal radial artery was measured before and after IB or infiltration anesthesia. AVF flow during the early and late postoperative period was evaluated using duplex ultrasound imaging. The rates of primary fistula failure were also compared. RESULTS: After anesthesia, preoperative radial arterial flow was 56 ± 8.6 mL/min in group IB vs 40.7 ± 6.11 mL/min in group C (P < .0001). Blood flow in the fistula, measured in mL/min at 3 hours, 7 days, and 8 weeks postoperatively, was also greater in group 1B vs group C, respectively, at 69.6 ± 7.9 vs 44.8 ± 13.8 (P < .001), 210.6 ± 30.9 vs 129 ± 36.1 (P < .001), and 680.6 ± 96.7 vs 405.3 ± 76.2 (P < 0.001). CONCLUSION: When used for AVF access surgery, infraclavicular brachial plexus block provides higher blood flow in the radial artery and AVF than is achieved with infiltration anesthesia.

Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia.

PURPOSE: To investigate how subsequent placement of a catheter into the epidural space after unintentional dural puncture for postoperative analgesia for 36-72 h affected the incidence of post-dural puncture headache (PDPH). METHODS: The records of 52 parturients who had had accidental dural puncture in cesarean delivery were reviewed. The parturients were assigned to two groups. Twenty-eight parturients were assigned to the study group, in whom an epidural catheter was inserted and was used for anesthesia and postoperative analgesia. Twenty-four parturients were assigned to the control group, in whom spinal anesthesia (n = 20) or general anesthesia (n = 4) was applied. For postoperative analgesia in patients with incision pain above visual analog scale (VAS) 3, 3 mg morphine in 15 ml saline was administered through the epidural catheter in the study group, while intramuscular meperidine or tramadol was administered in the control group. Once PDPH was observed, conservative treatment was tried first. If the headache persisted despite conservative treatment, an epidural blood patch was applied through the catheter or a reinserted epidural needle. RESULTS: The study group demonstrated significant reduction of the incidence of PDPH and reduction in the indication for an epidural blood patch compared to the control group (7.1% vs 58% [P = 0.000] and 3.6% vs 37.5% [P = 0.002], respectively). CONCLUSION: Subsequent catheter placement into the epidural space after unintentional dural puncture in cesarean delivery and leaving the catheter for postoperative analgesia for 36-72 h may reduce the incidence of PDPH.

A plantar flexion response to nerve stimulation indicates needle misplacement in the epidural/spinal space during psoas compartment block.

We report two cases of plantar flexion due to epidural misplacement of the needle during psoas compartment block, providing a response feedback for needle position during this procedure. In one case, the response occurred contralaterally, and in the other bilaterally. In the first patient, the cause of contralateral plantar flexion could not be determined and no injection was made. In the second patient, the anteriorposterior-fluoroscopic image showed that the tip of the needle was placed at the midline of the column. At this point, 3 ml of radiopaque medium was injected, and it diffused throughout the epidural space. Subsequently, single-shot epidural anesthesia was achieved by injection through this needle.

Subhypnotic propofol infusion plus dexamethasone is more effective than dexamethasone alone for the prevention of vomiting in children after tonsillectomy.

BACKGROUND: Postoperative vomiting (POV) is a common complication after tonsillectomy. Dexamethasone is known to decrease postsurgical vomiting. In this study, we compared the effects of dexamethasone alone to dexamethasone plus propofol on postoperative vomiting in children undergoing tonsillectomy. METHODS: In a randomized double-blinded study, we evaluated 80 healthy children, aged 4-12 years, who underwent tonsillectomy with or without adenoidectomy. After anesthesia was induced by inhalation of sevoflurane, 0.15 mg x kg(-1) dexamethasone and 2 microg x kg(-1) fentanyl was administered i.v. to all patients. The patients in the dexamethasone plus propofol group received 1 mg x kg(-1) propofol before intubation and continuously after intubation at a rate of 20 microg x kg(-1) x min(-1) until the surgery was completed. Data for postoperative vomiting were grouped into the following time periods: 0-4 and 4-24 h. Data were analyzed using a Student's t-test and chi-squared analysis. RESULTS: The percentage of patients exhibiting a complete response (defined as no retching or vomiting for 24 h) increased from 37.5% in the dexamethasone-alone group to 75% in the dexamethasone plus propofol group (P = 0.001). Twenty-two patients (55%) in the dexamethasone-alone and nine patients (22.5%) in the dexamethasone plus propofol groups experienced vomited during 0-4 h (P = 0.003). Eight patients in the dexamethasone-alone group and three patients in the dexamethasone plus propofol group received ondansetron as a rescue antiemetic during the postoperative period. CONCLUSION: For children undergoing tonsillectomy, intraoperative subhypnotic propofol infusion combined with dexamethasone treatment provides a better prophylaxis against postoperative vomiting than does dexamethasone alone.

The role of succinylcholine in the prevention of the obturator nerve reflex during transurethral resection of bladder tumors.

OBJECTIVE: To present our 8 year experience in the prevention of the obturator nerve reflex during transurethral resection of bladder tumors. METHODS: This study was performed in Ataturk University Hospital between 1999 and 2007. We retrospectively reviewed the records of 89 patients with inferolateral bladder tumors, who underwent transurethral resection under epidural or general anesthesia and requested obturator nerve reflex inhibition. Epidural anesthesia was administered to 57 patients, while the remaining 32 patients underwent general anesthesia via mask; and succinylcholine was administered prior to resection. RESULTS: Of the 57 patients received epidural anesthesia, 18 were diagnosed as inferolateral bladder tumors during endoscopy and had to undergo general anesthesia. Obturator nerve block was attempted preoperatively in 39 patients. However, a nerve identification failure, a hematoma, and 4 obturator nerve reflex events, despite the block, were observed and these patients were subjected to general anesthesia with succinylcholine. Fifty-six patients (32 patients initially had general anesthesia and 24 converted from epidural to general anesthesia) were all given succinylcholine prior to resection. CONCLUSION: Due to its mechanism of action, succinylcholine is completely effective and represents a simple alternative to obturator nerve block. No contraction was observed in any patient given succinylcholine.

Possible Subdural Block during Interscalene Brachial Plexus Block: A Case Report.

The interscalene block technique is widely used for a variety of procedures on the upper extremities. In general, this technique is safe and effective but is not without hazards. A case of subdural block resulting from an interscalene block is presented. In a 60-year-old female patient with carpal tunnel syndrome, sudden bradycardia, unconsciousness and respiratory arrest developed within several minutes after performing the block. At the end of the postinjectional third hour, she regained full consciousness, spontaneous breathing and full sensorial functions, except for profound anesthesia in the right arm. Within 6.5 hours of injection, right arm strength and sensation returned to normal; however, analgesia remained until the postinjectional ninth hour.

A new technique for laryngeal mask airway insertion in a newborn with pierre-robin syndrome: a case report.

Babies with Pierre Robin syndrome have serious life-threatening risks because of acute respiratory distress and difficult airway management. It is difficult to perform endotracheal intubation in these babies for general anesthesia. We present successful insertion of laryngeal mask airway in a neonate with typical clinical features of Pierre-Robin syndrome using a size 1 laryngeal mask airway for a ventriculoperitoneal shunt operation. The patient had micrognathia, glossoptosis with cleft palate, and partial trismus. His mouth opening was restricted to 0.6 cm. Anesthesia was deepened with sevoflurane, maintaining spontaneous ventilation, but laryngoscopy was impossible because of the limited mouth opening. After unsuccessful attempts to insert an LMA by standard and rotational techniques, it was inserted using a novel modified rotational LMA insertion technique, which we have termed the 'squeezing technique'.

Administration of local anesthetic through the epidural needle before catheter insertion improves the quality of anesthesia and reduces catheter-related complications.

Epidural catheter placement offers flexibility in block management. However, during epidural catheter insertion, complications such as paresthesia and venous and subarachnoid cannulation may occur, and suboptimal catheter placement can affect the quality of anesthesia. We performed this prospective, randomized, double-blind study to assess the effect of a single-injection dose of local anesthetic (20 mL of 2% lidocaine) through the epidural needle as a priming solution into the epidural space before catheter insertion. We randomized 240 patients into 2 equal groups and measured the quality of anesthesia and the incidence of complications. In the needle group (n = 100), catheters were inserted after injection of a full dose of local anesthetic through the needle. In the catheter group (n = 98), the catheters were inserted immediately after identification of the epidural space. Local anesthetic was then injected via the catheter. We noted the occurrence of paresthesia, inability to advance the catheter, or IV or subarachnoid catheter placement. Sensory and motor block were assessed 20 min after the injection of local anesthetic. Surgery was initiated when adequate sensory loss was confirmed. In the catheter group, the incidence of paresthesia during catheter placement was 31.6% compared with 11% in the needle group (P = 0.00038). IV catheterization occurred in 8.2% versus 2% of patients in the catheter and needle groups, respectively (P = 0.048). More patients in the needle group had excellent surgical conditions than the catheter group (89.6% versus 72.9; P < 0.003). We conclude that giving a single-injection dose via the epidural needle before catheter placement improves the quality of epidural anesthesia and reduces catheter-related complications.

Effects of sevoflurane and desflurane in CA1 after incomplete cerebral ischemia in rats.

OBJECTIVE: We compared the postischemic cerebral protective effects of sevoflurane and desflurane in rats with incomplete cerebral ischemia. METHODS: This study was performed in Ataturk University Medical Faculty in Erzurum, Turkey in 2003. All rats were anesthetized with 5% isoflurane, intubated and mechanically ventilated, then given 2% isoflurane in 70% nitrous oxide and 30% O2. The femoral artery was cannulated. Five minutes before ischemia, and at the end of ischemia, arterial blood was taken for plasma glucose, hematocrit and blood gas analysis. Hypotension was induced by hemorrhage, and then both common carotid arteries were clamped for 10 minutes. In the control group, the arteries were then unclamped and the rats were extubated. In the other 2 groups, isoflurane was discontinued after carotid artery unclamping, and either 2% sevoflurane or 6% desflurane in 70% nitrous oxide and 30% O2 was given for 30 minutes, after which the rats were extubated. Five days later, they were sacrificed, and histological scores in CA1 were graded on a scale 0-3. RESULTS: Histopathological outcome in sevoflurane and desflurane group was not different, but there were differences between sevoflurane and control (p<0.05), and desflurane and control (p<0.01). CONCLUSION: These data indicate that sevoflurane and desflurane have cerebral protective effects when given after ischemia.

Disappearance of phantom limb pain during cauda equina compression by spinal meningioma and gradual reactivation after decompression.

UNLABELLED: We describe a 65-yr-old woman, whose right lower limb had been amputated at the mid-femoral level because of complicated femur fracture sustained at the age of 5 yr. After amputation, she experienced phantom limb pain (PLP), which gradually decreased in intensity but persisted for 60 yr. At this point the pain diminished progressively, in parallel with the evolution of cauda equina compression caused by an intraspinal tumor. The PLP gradually reappeared over 3 mo after surgical removal of the tumor. IMPLICATIONS: We present a case in which phantom limb pain (PLP) in an amputated leg disappeared during cauda equina compression by meningioma and reactivated after surgical decompression. This case suggests that complete compression or blockade of nerves, a nerve plexus, the cauda equina, or the medullary cord may result in suppression of PLP, and decompression of or recovery from the block may cause reactivation.

Determination of in vitro antioxidant and radical scavenging activities of propofol.

Propofol (2,6-diisopropylphenol) is a hypnotic intravenous agent with in vivo antioxidant properties. This study was undertaken to examine the in vitro antioxidant activity of propofol using different antioxidant tests including by 1,1-diphenyl-2-picryl-hydrazil (DPPH.) radical scavenging, metal chelating, hydrogen peroxide scavenging, superoxide anion radical scavenging, reducing power and total antioxidant activities. At the concentrations of 25, 50, and 75 microg/ml, propofol exhibited 97.7, 98.6 and 100% inhibition on peroxidation of linoleic acid emulsion, respectively. On the other hand, at the 75 microg/ml concentration of standard antioxidants such as butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT) and alpha-tocopherol exhibited 88.7, 94.5, and 70.4% inhibition on peroxidation of linoleic acid emulsion, respectively. In addition, at same concentrations, propofol was shown that it had effective reducing power, DPPH. free radical scavenging, superoxide anion radical scavenging, hydrogen peroxide scavenging and metal chelating activities. These various antioxidant activities were compared to standard antioxidants such as BHA, BHT and alpha-tocopherol. These results indicate that propofol prevents lipid peroxidation and radicalic chain reactions. At the same time, propofol revealed more effective antioxidant capacity than BHA, BHT and alpha-tocopherol.