Comparison of Intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery.

The aim of our study was to compare bilateral erector spinae plane block (ESPB) efficacy on pain management with patient controlled analgesia (PCA) during the perioperative period in patients scheduled for coronary artery bypass grafting (CABG). After ethics committee approval (2019-7/31 dated 09.04.2019) from the Bursa Uludag University Medical Trials Ethics Committee, (https://uludag.edu.tr/buuetikkurulu) ASA II-III, 50 patients aged between 18-80 years were included. They were randomly divided into two groups, ESPB (n=25) and control (n=25). In the preoperative period, bilateral ESPB with ultrasonography was applied to both groups with 0.25% bupivacaine (0.5 ml/kg) + dexamethasone (8 mg) or saline, respectively. PCA prepared with morphine was given to all patients postoperatively. Perioperative opioid use, extubation times, coughing/resting Visual Analog Scale (VAS) scores, duration for first PCA bolus dose requirement, rescue analgesia needs, mobilization times, and opioid side effects were evaluated. In the ESPB group, compared to the control group, intraoperative fentanyl consumption was lower (P=0.001). During the postoperative period; extubation time was shorter, the need for initial PCA was much later, morphine consumption and need for rescue analgesia was less (P=0.001; P<0.001; P<0.001; P=0.009, respectively). The postoperative VAS scores were lower for each measurement period (P<0.05). Opioid-related side effects were more common in the control group (P=0.040). First mobilization time in ESPB group was earlier (P<0.001). As a result, ESPB has a significant analgesic effect in CABG patients. It was concluded that bilateral ESPB reduces opioid requirement compared to intravenous morphine PCA alone and provides better pain management and more comfortable recovery.

Comparison of intraoperative and post-operative effects of serratus anterior plane block performed with ultrasound and infiltration block in patients undergoing video-assisted thoracoscopic surgery.

OBJECTIVES: We aimed to compare the intraoperative and post-operative analgesic activities of the preventive applied serratus anterior plane (SAP) block and infiltration block in patients undergoing video-assisted thoracoscopic surgery (VATS). METHODS: The study was carried out in 60 patients aged between 18 and 80 who were eligible for elective VATS, with the American Society of Anesthesiologists classification I-II, following ethical committee approval and written informed consent form. Patients were divided into two groups as SAP (group serratus anterior plane block [SAPB]) and group infiltration block after routine monitoring and general anesthesia induction by recording demographic data after randomization. Hemodynamic data of all patients were recorded before, after induction and within intraoperative 30 min period. Patient controlled analgesia (PCA) prepared with morphine was applied to all patients postoperatively. Intraoperative hemodynamic data and opioid consumption of patients, resting time, and coughing visual analog scale, time to first PCA dose, post-operative opioid consumption, rescue analgesic requirement, mobilization times, opioid side effects, and patient and surgical team's satisfaction were evaluated. RESULTS: Intraoperative hemodynamic data and opioid consumption were similar between the two groups. Post-operative pain scores (0 and 30 min, 1, 2, 4, 8, and 12 h) were lower in the SAPB group (p<0.005) and time to use the first PCA (p=0.002) was longer in the SAPB group. Post-operative PCA and rescue analgesic requirement were lower in the SAPB group (p=0.002, p=0.00). It was found that the first mobilization time was shorter in the SAPB group (p=0.003), and opioid-related side effects were similar in both groups (p=0.067). Patient and surgical team satisfaction was high in the SAPB group (p=0.004, p=0.000). CONCLUSION: As a result, more effective post-operative analgesia was provided with preventively SAPB, compared to infiltration block in patients undergoing VATS.

The effect of combined pulsed radiofrequency treatment to dorsal root ganglion with transforaminal epidural steroid injection on pain.

OBJECTIVES: We aimed to compare the treatment response with simultaneous application of transforaminal epidural steroid injection (TESI) and pulsed radiofrequency (PRF) to the lumbar dorsal root ganglion (DRG) with TESI in patients with chronic lumbar radicular pain. METHODS: A total of 129 patients were enrolled. TESI was performed to 67 patients and TESI+DRG-PRF was performed to 62 patients. Demographic data, surgical records, and medications, side, and level of the procedure were recorded. Patients were evaluated on the pre-operative and post-operative 10th day, 1st and 3rd month follow-up visits, and visual analog scale (VAS, 0-10) scores, and patients' satisfaction assessment on the 3rd month follow-up were collected. A successful therapeutic response was defined as a 50% or more reduction in VAS scores. RESULTS: In both groups, post-operative VAS scores were significantly lower than the pre-operative levels (p<0.001). VAS scores in the TESI+DRG-PRF group were significantly lower than the TESI group at all follow-up periods (p˂0.001). Reduction ratios in VAS scores were significantly higher in the TESI+DRG-PRF group in all follow-up visits (p˂-0.001). Satisfaction levels were significantly higher in the TESI+DRG-PRF group (p˂0.01). CONCLUSION: According to our study, TESI provides short-moderate pain relief in patients with chronic lumbar radicular pain. A simultaneous application of PRF in the same session with TESI should be considered as an option to improve the treatment response.

Comparison of efficacy between the genicular nerve block and the popliteal artery and the capsule of the posterior knee (IPACK) block for total knee replacement surgery: A prospective randomized controlled study.

OBJECTIVE: The aim of this study was to compare the efficacy of popliteal artery and the capsule of the posterior knee (IPACK) block and genicular nerve block on postoperative pain scores, the need for rescue analgesics, range of motion (ROM), walking distance, and perioperative monitorization variables in patients undergoing total knee replacement (TKR) surgery. METHODS: Sixty American Society of Anesthesiologists (ASA) physical status I-III patients were enrolled in this study and then were randomly assigned into three groups: the IPACK block group (17 female, 3 male; mean age=67.5±1.4 years), genicular nerve block (16 female, 4 male; mean age=68±1.76 years), and the control group (13 female, 7 male; mean age=63±1.67years). All the patients underwent TKR under spinal anesthesia. The visual analog scale (VAS) score, mobility, pre- and intra-operative monitorization of systolic and diastolic holding area, non-invasive blood pressure, heart rate, and SPO 2 were compared between the groups. RESULTS: Patients in the IPACK and genicular block groups had a significantly lower visual analogous scale (VAS) at postoperative 4 hours (p<0.01), 8h (p<0.01), 12h (p<0.01), and 24h (p<0.05). VAS score was significantly lower in the genicular block group at the postoperative 4h (5.5±0.55) and 8h (5.0±0.53) in the mobile state compared to the IPACK (8.0±0.47 and 8.0±0.43, respectively) and the control group (9.5±0.20; 10±0.28, respectively) (p< 0.01). The use of patient-controlled-analgesia (PCA) devices and button push count for analgesics demand were significantly lower in the genicular block group on the immediate postoperative period (p<0.01 at the postoperative 0 to 4 h). The total consumption of morphine equivalents on the postoperative day 0 was significantly lower in the genicular block group (p<0.01, and p<0.001 for IPACK and control groups, respectively). The degree of flexion was significantly higher in the genicular block group at the postoperative 12h compared to the IPACK and the control group (p<0.001). The length of hospital stay was significantly lower in the genicular block group compared to the IPACK and the control group (p<0.05 for both variables). CONCLUSION: IPACK and genicular blocks both are effective in improving patient comfort during and after TKR surgery and reducing the potential need for systemic analgesic and opioids. The genicular block seems to be a promising technique that can offer improved pain management in the immediate and early postoperative period without adverse effects on systemic and motor variables.

Investigation of Effectiveness of Pulsed Radiofrequency With Multifunctional Epidural Electrode for Low Back Pain.

AIM: Low back pain affects many people at some point in their life. Whenever pharmacologic and other conservative treatments of chronic pain fail, ablative and interventional methods are attempted on the assumption that interrupting nerve conduction prevents central pain cognition. Pulsed radiofrequency using multifunctional epidural electrodes can be used for multiple etiologies of chronic low back and leg pain with a low complication rate and minimal side effects. METHODS: The records of the 188 patients who underwent pulsed radiofrequency with multifunctional epidural electrode between October 2014 and March 2017 in Algology clinic were examined retrospectively. Visual analogue scale (VAS) for pain, response to straight leg raising test (SLR), lumbar range of motion, analgesic use, patient satisfaction score, need for open operation or other interventional procedure were collected. RESULTS: VAS and SLR tests were found to be significantly improved compared with the preoperative values. The VAS scores at the 10th day and first, third and sixth months were significantly decreased compared to baseline scores (p<0.001). Also, SLR tests were significantly improved compared to baseline scores at the same intervals (p<0.001). CONCLUSION: Pulsed radiofrequency with multifunctional epidural electrode is a safe and effective method for low back pain which is caused by several pathologies.

The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children.

INTRODUCTION: We compared the effects of various surgical positions, with and without the Valsalva manoeuvre, on the diameter of the right internal jugular vein (RIJV). METHODS: We recruited 100 American Society of Anesthesiologists physical status class I patients aged 2-12 years. The patients' heart rate, blood pressure, peripheral oxygen saturation and end-tidal CO2 pressure were monitored. Induction of anaesthesia was done using 1% propofol 10 mg/mL and fentanyl 2 µg/kg, while maintenance was achieved with 2% sevoflurane in a mixture of 50/50 oxygen and air (administered via a laryngeal mask airway). The RIJV diameter was measured using ultrasonography when the patient was in the supine position. Thereafter, it was measured when the patient was in the supine position + Valsalva, followed by the Trendelenburg, Trendelenburg + Valsalva, reverse Trendelenburg, and reverse Trendelenburg + Valsalva positions. A 15° depression or elevation was applied for the Trendelenburg position, and an airway pressure of 20 cmH2O was applied in the Valsalva manoeuvre. During ultrasonography, the patient's head was tilted 20° to the left. RESULTS: When compared to the mean RIJV diameter in the supine position, the mean RIJV diameter was significantly greater in all positions (p < 0.001) except for the reverse Trendelenburg position. The greatest increase in diameter was observed in the Trendelenburg position with the Valsalva manoeuvre (p < 0.001). CONCLUSION: In paediatric patients, the application of the Trendelenburg position with the Valsalva manoeuvre gave the greatest increase in RIJV diameter. The reverse Trendelenburg position had no significant effect on RIJV diameter.

Iliohypogastric/ilioinguinal nerve block in inguinal hernia repair for postoperative pain management: comparison of the anatomical landmark and ultrasound guided techniques / Bloqueio dos nervos ílio-hipogástrico/ilioinguinal em correção de hérnia inguinal para tratamento da dor no pós-operatório: comparação entre a técnica de marcos anatômicos e a guiada por ultrassom / Bloqueo de los nervios ileohipogástrico/ilioinguinal en corrección de hernia inguinal para el tratamiento del dolor en el postoperatorio: comparación entre la técnica de marcas anatómicas y la guiada por ultrasonido

Objectives: The purpose of this study is to compare the efficacy of iliohypogastric/ilioinguinal nerve blocks performed with the ultrasound guided and the anatomical landmark techniques for postoperative pain management in cases of adult inguinal herniorrhaphy. Methods: 40 patients, ASA I-II status were randomized into two groups equally: in Group AN (anatomical landmark technique) and in Group ultrasound (ultrasound guided technique), iliohypogastric/ilioinguinal nerve block was performed with 20 ml of 0.5% levobupivacaine prior to surgery with the specified techniques. Pain score in postoperative assessment, first mobilization time, duration of hospital stay, score of postoperative analgesia satisfaction, opioid induced side effects and complications related to block were assessed for 24 h postoperatively. Results: VAS scores at rest in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p < 0.01 or p < 0.001). VAS scores at movement in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p < 0.001 in all time points). While duration of hospital stay and the first mobilization time were being found significantly shorter, analgesia satisfaction scores were found significantly higher in ultrasound Group (p < 0.05, p < 0.001, p < 0.001 respectively). Conclusion: According to our study, US guided iliohypogastric/ilioinguinal nerve block in adult inguinal herniorrhaphies provides a more effective analgesia and higher satisfaction of analgesia than iliohypogastric/ilioinguinal nerve block with the anatomical landmark technique. Moreover, it may be suggested that the observation of anatomical structures with the US may increase the success of the block, and minimize the block-related complications. .

Objetivo: Comparar a eficácia de bloqueios dos nervos ílio-hipogástrico/ilioinguinal feitos com a técnica guiada por ultrassom e a de marcos anatômicos para o manejo da dor no pós-operatório em casos de herniorrafia inguinal em adultos. Métodos: Foram randomicamente divididos 40 pacientes, estado físico ASA I-II, em dois grupos iguais: nos grupos AN (técnica de marcos anatômicos) e US (técnica guiada por ultrassom), o bloqueio dos nervos ílio-hipogástrico/ilioinguinal foi feito com 20 mL de levobupivacaína a 0,5% antes da cirurgia com as técnicas especificadas. Escore de dor na avaliação pós-operatória, tempo de primeira mobilização, tempo de internação hospitalar, escore de satisfação com a analgesia no pós-operatório, efeitos colaterais induzidos por opiáceos e complicações relacionadas ao bloqueio foram avaliados durante 24 horas de pós-operatório. Resultados: Escores EVAem repouso na sala de recuperação e todos os valores clínicos durante o acompanhamento foram significativamente menores no grupo ultrassom (p < 0,01 ou p < 0,001). Escores EVA em movimento na sala de recuperação e todos os valores clínicos durante o acompanhamento foram significativamente menores no grupo ultrassom (p < 0,001 em todos os tempos avaliados). Enquanto os tempos de internação e da primeira mobilização foram significativa-mente menores, os índices de satisfação com a analgesia foram significativamente maiores no grupo ultrasom (p<0,05, p< 0,001, p< 0,001, respectivamente). Conclusão: De acordo com o nosso estudo, o bloqueio dos nervos ílio-hipogástrico/ilioinguinal guiado por US em herniorrafias inguinais em adultos proporciona uma analgesia mais eficaz e maior satisfação com a analgesia ...

Objetivo: El objetivo de este estudio fue comparar la eficacia de bloqueos de los nervios ileohipogástrico/ilioinguinal realizados con la técnica guiada por ultrasonido y la de marca anatómicas para el manejo del dolor en el postoperatorio en casos de herniorrafia inguinal en adultos. Métodos: 40 pacientes, estado físico ASA I-II, fueron aleatoriamente divididos en 2 grupos iguales: grupos con técnica de marcas anatómicas) y grupo con técnica guiada por ultrasonido. El bloqueo de los nervios iliohipogástrico/ilioinguinal fue realizado con 20 mL de levobupivacaína al 0,5% antes de la cirugía con las técnicas especificadas. La puntuación de dolor en la evaluación postoperatoria, tiempo de primera movilización, tiempo de ingreso hospitalario, puntuación de satisfacción con la analgesia en el postoperatorio, efectos colaterales inducidos por opiáceos y complicaciones relacionadas con el bloqueo fueron evaluados durante 24 h de postoperatorio. Resultados: Las puntuaciones EVA en reposo en la sala de recuperación y todos los valores clínicos durante el seguimiento fueron significativamente menores en el grupo con técnica guiada por ultrasonido (p < 0,01 o p < 0,001). Las puntuaciones EVA en movimiento en la sala de recuperación y todos los valores clínicos durante el seguimiento fueron significativamente menores en el grupo con técnica guiada por ultrasonido (p < 0,001 en todos los tiempos calculados). Mientras que los tiempos de ingreso y de la primera movilización fueron significativamente menores, los índices de satisfacción con la analgesia fueron significativamente mayores en el grupo ultrasonido (p < 0,05; p < 0,001; p < 0,001 respectivamente). Conclusión: De acuerdo con nuestro estudio, el bloqueo de los nervios iliohipogástrico/ilioinguinal guiado por ultrasonido en herniorrafias ...

[Iliohypogastric/ilioinguinal nerve block in inguinal hernia repair for postoperative pain management: comparison of the anatomical landmark and ultrasound guided techniques]. / Bloqueio dos nervos ílio-hipogástrico/ilioinguinal em correção de hérnia inguinal para tratamento da dor no pós-operatório: comparação entre a técnica de marcos anatômicos e a guiada por ultrassom.

OBJECTIVES: The purpose of this study is to compare the efficacy of iliohypogastric/ilioinguinal nerve blocks performed with the ultrasound guided and the anatomical landmark techniques for postoperative pain management in cases of adult inguinal herniorrhaphy. METHODS: 40 patients, ASA I-II status were randomized into two groups equally: in Group AN (anatomical landmark technique) and in Group ultrasound (ultrasound guided technique), iliohypogastric/ilioinguinal nerve block was performed with 20ml of 0.5% levobupivacaine prior to surgery with the specified techniques. Pain score in postoperative assessment, first mobilization time, duration of hospital stay, score of postoperative analgesia satisfaction, opioid induced side effects and complications related to block were assessed for 24h postoperatively. RESULTS: VAS scores at rest in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p<0.01 or p<0.001). VAS scores at movement in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p<0.001 in all time points). While duration of hospital stay and the first mobilization time were being found significantly shorter, analgesia satisfaction scores were found significantly higher in ultrasound Group (p<0.05, p<0.001, p<0.001 respectively). CONCLUSION: According to our study, US guided iliohypogastric/ilioinguinal nerve block in adult inguinal herniorrhaphies provides a more effective analgesia and higher satisfaction of analgesia than iliohypogastric/ilioinguinal nerve block with the anatomical landmark technique. Moreover, it may be suggested that the observation of anatomical structures with the US may increase the success of the block, and minimize the block-related complications.

Preemptive wound infiltration in lumbar laminectomy for postoperative pain: comparison of bupivacaine and levobupivacaine.

AIM: Patients usually suffer significant pain after lumbar laminectomy. Wound infiltration with local anesthetics is a useful method for postoperative pain control. Our aim was to compare the efficacies of preemptive wound infiltration with bupivacaine and levobupivacaine. MATERIAL AND METHODS: 60 patients were randomized three groups as follows: Group L wound infiltration with 20 mL 0.25% levobupivacaine and 40 mg methylprednisolone just before wound closure; Group B wound infiltration with 20 mL 0.25% bupivacaine and 40 mg methylprednisolone before closure; Group C had this region infiltrated with 20 ml physiological saline. Demographic data, vital signs, postoperative pain scores and morphine usage were recorded. RESULTS: First analgesic requirement time was significantly shorter in the control group compared to other two groups (p < 0.001). Group B had the lowest cumulative morphine consumption at the end of 24 hours within 0-4, 4-12 and 12-24 hours time intervals and the values were not significant when compared with Group L, however the consumption of both groups was significantly lower compared to the control group (p < 0.001). CONCLUSION: Our data suggest that preoperative infiltration of the wound site with bupivacaine or levobupivacaine provides similarly effective pain control with reduced opiate dose after unilateral lumbar laminectomy.

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.

Comparison of blunt and sharp needles for transforaminal epidural steroid injections.

OBJECTIVES: The aim of this study was to compare the sharp and blunt needles in order to determine the incidence of complications during transforaminal anterior epidural steroid injections. METHODS: In this retrospective study, 185 cases that undergo transforaminal epidural steroid injection with sharp or blunt needles were evaluated between June 2004 and December 2008. Patients age, sex, diagnosis, needle type (sharp or blunt), volume of local anesthetic and steroid injected, complications (paresthesia, dural puncture, bleeding, paralysis, intravascular penetration, headache, local back pain, temporary motor loss in lower extremities) was recorded. RESULTS: 3 cases in blunt needle group and 8 cases in sharp needle group showed paresthesia during the procedure. The difference was not found to be significant among the groups. Vascular penetration was observed in 2 cases in blunt and 13 cases in sharp needle group and the difference between groups was statistically significant (p<0.001). Dural puncture and headache incidence were not significant when the two groups are compared. The local back pain at the injection site had a higher incidence in the blunt needle group. CONCLUSION: When using the blunt needles, vascular penetration and paresthesia were less during transforaminal epidural steroid injections. Therefore blunt needles seem to be more advantageous.

Comparison of esmolol to nitroglycerine in controlling hypotension during nasal surgery.

OBJECTIVE: The aim of this study was to compare esmolol to nitroglycerine in terms of effectiveness in controlling hypotension during nasal surgery. MATERIALS AND METHODS: After approval by our institutional Ethics Committee, 40 patients were recruited and randomized into two drug groups: esmolol (Group E) and nitroglycerine (Group N). In group E, a bolus dose of 500 µg/kg esmolol was administered over 30 sec followed by continuous administration at a dose of 25-300 µg/ kg/min to maintain systolic arterial pressure at 80 mmHg. In group N, nitroglycerine was administered at a dose of 0.5-2 µg/kg/min. RESULTS: During the hypotensive period, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, and heart rate were decreased 24%, 33%, 27% and 35%, respectively, in group E (p<0.001, p<0.001, p<0.001, p<0.001) and were decreased 30%, 33%, 34% and 23%, respectively, in group N (p<0.001, p<0.001, p<0.001, p<0.001). The decrease in heart rate was higher in group E during the hypotensive period (p=0.048). During the recovery period, diastolic arterial pressure and heart rate were decreased 9% and 18%, respectively, in group E (p=0.044, p<0.001). Systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure were decreased 7%, 3% and 7%, respectively, in group N (p=0.049, p=0.451, p=0.045). CONCLUSION: Esmolol provides hemodynamic stability and good surgical field visibility and should be considered as an alternative to nitroglycerine.

Conscious sedation for endoscopic retrograde cholangiopancreatography: dexmedetomidine versus midazolam.

OBJECTIVE: Midazolam and dexmedetomidine, which are used for sedation during endoscopic retrograde cholangiopancreatography, were compared to evaluate the differences in efficacy, hemodynamics, and side effects. MATERIALS AND METHODS: Fifty patients aged between 18 and 80 were randomly assigned to two groups according to American Society of Anesthesiologists (ASA) classification: Group M received midazolam with an initial bolus infusion of 0.04 mg/kg intravenously (i.v.), followed by additional doses of 0.5 mg i.v. midazolam, titrated to achieve a Ramsay sedation scale score of 3-4. Group D received dexmedetomidine with an initial bolus infusion of 1 mcg/kg/hr i.v. over 10 minutes, followed by a continuous infusion of 0.2-0.7 mcg/kg/hr, titrated to achieve an RSS of 3-4. A Mini Mental Status Examination (MMSE) was performed prior to sedation and in the recovery room once the Modified Aldrete Score (MAS) reached 9-10. Patient heart rates, arterial pressure and pain were evaluated. RESULTS: Patients in Group D had lower heart rates at 20, 25, 30, 35 and 40 minutes following the initiation of sedation (p<0.05). There was no statistical difference in arterial pressure, RSS, MMSE or respiratory rate between the two groups. Coughing, nausea and vomiting occurred in 3 patients in Group M (12%), whereas no patient in Group D experienced these symptoms. The procedure elicited a gag response in 7 patients in Group M (28%) and in 4 patients in Group D (16%), with no significant difference between groups (p>0.05). When patient and surgeon satisfaction was compared between the two groups, Group D showed higher surgeon satisfaction scores (p<0.05). CONCLUSION: The use of dexmedetomidine for conscious sedation during short, invasive procedures, such as endoscopic retrograde cholangiopancreatography, could be a superior alternative to the use of midazolam.

Comparison of two different doses of intrathecal levobupivacaine for transurethral endoscopic surgery.

OBJECTIVE: To evaluate the effects of two different spinal isobaric levobupivacaine doses on spinal anesthesia characteristics and to find the minimum effective dose for surgery in patients undergoing transurethral resection (TUR) surgery. MATERIALS AND METHODS: Fifty male patients undergoing TUR surgery were included in the study and were randomized into two equal groups: Group LB10 (n=25): 10 mg 0.5% isobaric levobupivacaine (2 ml) and Group LB15 (n=25): 15 mg 0.75% isobaric levobupivacaine (2 ml). Spinal anesthesia was administered via a 25G Quincke spinal needle through the L3-4 intervertebral space. Sensorial block levels were evaluated using the 'pin-prick test', and motor block levels were evaluated using the 'Bromage scale'. The sensorial and motor block characteristics of patients during intraoperative and postoperative periods and recovery time from spinal anesthesia were evaluated. RESULTS: In three cases in the Group LB10, sensorial block did not reach the T10 level. Complete motor block (Bromage=3) did not occur in eight cases in the Group LB10 and in five cases in the Group LB15. The highest sensorial dermatomal level detected was higher in Group LB15. In Group LB15, sensorial block initial time and the time of complete motor block occurrence were significantly shorter than Group LB10. Hypotension was observed in one case in Group LB15. No significant difference between groups was detected in two segments of regression times: the time to S2 regression and complete sensorial block regression time. Complete motor block regression time was significantly longer in Group LB15 than in Group LB10 (p<0.01). CONCLUSION: Our findings showed that the minimum effective spinal isobaric levobupivacaine dose was 10 mg for TUR surgery.

Intravenous dexmedetomidine, but not midazolam, prolongs bupivacaine spinal anesthesia.

PURPOSE: Midazolam has only sedative properties. However, dexmedetomidine has both analgesic and sedative properties that may prolong the duration of sensory and motor block obtained with spinal anesthesia. This study was designed to compare intravenous dexmedetomidine with midazolam and placebo on spinal block duration, analgesia, and sedation in patients undergoing transurethral resection of the prostate. METHODS: In this double-blind randomized placebo-controlled trial, 75 American Society of Anesthesiologists' I and II patients received dexmedetomidine 0.5 microg . kg(-1), midazolam 0.05 mg . kg(-1), or saline intravenously before spinal anesthesia with bupivacaine 0.5% 15 mg (n = 25 per group). The maximum upper level of sensory block and sensory and motor regression times were recorded. Postoperative analgesic requirements and sedation were also recorded. RESULTS: Sensory block was higher with dexmedetomidine (T 4.6 +/- 0.6) than with midazolam (T 6.4 +/- 0.9; P < 0.001) or saline (T 6.4 +/- 0.8; P < 0.001). Time for sensory regression of two dermatomes was 145 +/- 26 min in the dexmedetomidine group, longer (P < 0.001) than in the midazolam (106 +/- 39 min) or the saline (97 +/- 27 min) groups. Duration of motor block was similar in all groups. Dexmedetomidine also increased the time to first request for postoperative analgesia (P < 0.01 compared with midazolam and saline) and decreased analgesic requirements (P < 0.05). The maximum Ramsay sedation score was greater in the dexmedetomidine and midazolam groups than in the saline group (P < 0.001). CONCLUSION: Intravenous dexmedetomidine, but not midazolam, prolonged spinal bupivacaine sensory blockade. It also provided sedation and additional analgesia.

Internal jugular vein cannulation: an ultrasound-guided technique versus a landmark-guided technique.

OBJECTIVES: To compare the landmark-guided technique versus the ultrasound-guided technique for internal jugular vein cannulation in spontaneously breathing patients. METHODS: A total of 380 patients who required internal jugular vein cannulation were randomly assigned to receive internal jugular vein cannulation using either the landmark- or ultrasound-guided technique in Bursa, Uludag University Faculty of Medicine, between April and November, 2008. Failed catheter placement, risk of complications from placement, risk of failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization and the demographics of each patient were recorded. RESULTS: The overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). Carotid puncture rate and hematoma were more frequent in the landmark group than in the ultrasound-guided group (p < 0.05). The number of attempts for successful placement was significantly higher in the landmark group than in the ultrasound-guided group, which was accompanied by a significantly increased access time observed in the landmark group (p < 0.05 and p < 0.01, respectively). Although there were a higher number of attempts, longer access time, and a more frequent complication rate in the landmark group, the success rate was found to be comparable between the two groups. CONCLUSION: The findings of this study indicate that internal jugular vein catheterization guided by real-time ultrasound results in a lower access time and a lower rate of immediate complications.

Preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy.

OBJECTIVES: Paracetamol is primarily thought to be a cyclooxygenase inhibitor acting through the central nervous system. Indirect effects of paracetamol are through the serotoninergic system as a non-opioid analgesic. In this study, total abdominal hysterectomy patients were given intravenous (iv) paracetamol 1 g preoperatively or intraoperatively to assess its postoperative analgesic effects. METHODS: 90 patients undergoing total abdominal hysterectomy were enrolled into the study. Patients were randomized into three groups: in Group I, iv paracetamol 1 g was given 30 minutes prior to induction. In Group II, iv paracetamol 1 g was given prior to skin closure. Group III served as the control group and received saline as placebo. Postoperatively, all patients received morphine via patient-controlled analgesia pump. Postoperatively, rest and activity pain scores, sedation scores, hemodynamic parameters, postoperative morphine consumption, side effects, patient satisfaction, and total hospital stay were recorded. RESULTS: In the control group, at rest and movement pain scores and total morphine consumption via patient-controlled analgesia were higher than in Groups I and II. When Groups I and II were compared, total morphine consumption was much greater in Group II. Intravenous paracetamol intraoperatively and postoperatively did not result in any hemodynamic effects. CONCLUSION: In total abdominal hysterectomy, preemptive iv paracetamol 1 g provided good quality postoperative analgesia, with decreased consumption of morphine and minimal side effects.

Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis.

STUDY DESIGN: Randomized single-blind controlled trial. OBJECTIVE: We aimed to compare the effects of epidural steroid injections and physical therapy program on pain and function in patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is one of the most common degenerative spinal disorders among elderly population. Initial treatment of this disabling painful condition is usually conservative including analgesics, nonsteroidal anti-inflammatory drugs, exercise, physical therapy, or epidural steroid injections. Owing to lack of sufficient data concerning the effectiveness of conservative treatment in LSS, we aimed to compare the effectiveness of epidural steroid injections and physical therapy program in a randomized controlled manner. METHODS: A total of 29 patients diagnosed as LSS were randomized into 3 groups. Group 1 (n = 10) received an inpatient physical therapy program for 2 weeks, group 2 (n = 10) received epidural steroid injections, and group 3 (n = 9) served as the controls. All study patients additionally received diclofenac and a home-based exercise program. The patients were evaluated at baseline, 2 weeks, 1 month, 3 months, and 6 months after treatment by finger floor distance, treadmill walk test, sit-to-stand test, weight carrying test, Roland Morris Disability Index, and Nottingham Health Profile. RESULTS: Both epidural steroid and physical therapy groups have demonstrated significant improvement in pain and functional parameters and no significant difference was noted between the 2 treatment groups. Significant improvements were also noted in the control group. Pain and functional assessment scores (RMDI, NHP physical activity subscore) were significantly more improved in group 2 compared with controls at the second week. CONCLUSION: Epidural steroid injections and physical therapy both seem to be effective in LSS patients up to 6 months of follow-up.

Internal jugular vein cannulation: an ultrasound-guided technique versus a landmark-guided technique

OBJECTIVES: To compare the landmark-guided technique versus the ultrasound-guided technique for internal jugular vein cannulation in spontaneously breathing patients. METHODS: A total of 380 patients who required internal jugular vein cannulation were randomly assigned to receive internal jugular vein cannulation using either the landmark- or ultrasound-guided technique in Bursa, Uludag University Faculty of Medicine, between April and November, 2008. Failed catheter placement, risk of complications from placement, risk of failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization and the demographics of each patient were recorded. RESULTS: The overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). Carotid puncture rate and hematoma were more frequent in the landmark group than in the ultrasound-guided group (p < 0.05). The number of attempts for successful placement was significantly higher in the landmark group than in the ultrasound-guided group, which was accompanied by a significantly increased access time observed in the landmark group (p < 0.05 and p < 0.01, respectively). Although there were a higher number of attempts, longer access time, and a more frequent complication rate in the landmark group, the success rate was found to be comparable between the two groups. CONCLUSION: The findings of this study indicate that internal jugular vein catheterization guided by real-time ultrasound results in a lower access time and a lower rate of immediate complications.

Intrathecal morphine in anesthesia for cesarean delivery: dose-response relationship for combinations of low-dose intrathecal morphine and spinal bupivacaine.

STUDY OBJECTIVE: To evaluate the quality of analgesia and the severity of side effects of intrathecal morphine administered for a dose range of 0.0 to 0.4 mg for postcesarean analgesia with low-dose bupivacaine. DESIGN: Double-blind, randomized study. SETTING: University hospital. PATIENTS: 100 ASA physical status I and II term parturients undergoing cesarean delivery with spinal anesthesia in the operating room. INTERVENTIONS: Patients were randomized to one of 5 groups to receive 0.0, 0.1, 0.2, 0.3, or 0.4 mg intrathecal morphine in addition to low-dose (7.5 mg) heavy bupivacaine. Each patient received intravenous (IV) patient-controlled analgesia (PCA) with morphine after the operation. MEASUREMENTS: 24-hour IV PCA morphine use and visual analog scores for pain were recorded. The severity score (4-point scale) of nausea, vomiting, and pruritus were assessed intraoperatively and at 4-hour intervals during the first 24 hours postoperatively. MAIN RESULTS: PCA morphine use was higher in the control group (0.0 mg) than in groups receiving 0.1, 0.2, 0.3, or 0.4 mg intrathecal morphine. There was no difference in IV PCA morphine use between the 0.1 and 0.4-mg groups, despite a 4-fold increase in intrathecal morphine dose. There was no difference between groups in nausea and vomiting, but pruritus increased in direct proportion to the dose of intrathecal morphine (linear regression, P = 0.0001). CONCLUSIONS: The dose of 0.1 mg intrathecal morphine produces analgesia comparable with doses as high as 0.4 mg, with significantly less pruritus when combined with low-dose bupivacaine.