The Clinical Importance of Optic Nerve Sheath Diameter in Patients with Traumatic Brain Injury: Preliminary Report.

Objective: Traumatic brain injury (TBI) is a serious health problem that is related to an increased mortality. In cases of severe TBI, the prediction of prognosis is essential. The enlargement of the optic nerve sheath diameter (ONSD) shows an increased intracranial pressure and is associated with poor outcomes. In this study, we aimed to evaluate the prognostic value of ONSD in patients with severe TBI. Methods: Forty-four patients with severe TBI were retrospectively enrolled in the study. The patients were divided into two groups: survivors (n=17) and non-survivors (n=27). Baseline characteristics, clinical data, Glasgow coma scale (GCS) on hospital admission, brain computed tomography (CT) results, injury severity score (ISS), and Marshall score were recorded for all patients. ONSD was calculated at 3 mm distance from the globe, immediately below the sclera. Results: The ONSD on the initial CT was significantly higher in non-survivors compared with survivors (6.83±1.40 vs. 6.40±1.36, p<0.05). In addition, ISS and Marshall score were significantly higher, whereas GCS was significantly lower in non-survivors. ONSD was positively correlated with Marshall score (r=0.332, p<0.05). Receiver operating characteristics analysis demonstrated that ONSD ≥6.61 had a sensitivity of 70.4% and specificity of 64.7% for predicting mortality. It was shown that ONSD ≥6.61 had a 4.3-fold increased risk for in-hospital mortality (odds ratio: 4.35; 95% confidence interval: 1.195-15.865; p<0.05). Conclusions: The enlargement of ONSD on initial CT was detected to be associated with increased in-hospital mortality in patients with severe TBI.

Does Sugammadex Suppress Allergic Inflammation Due to Rocuronium in Animal Model of Rat?

INTRODUCTION AND OBJECTIVES: There are a few reports in the literature about the successful use of sugammadex in the treatment of hypersensitivity reactions caused by rocuronium; however, the pathophysiological mechanism is still unknown. This study aims to investigate the changes caused by rocuronium in the lung and the effect of sugammadex on these changes with biochemical, light microscopic and immunohistochemical parameters on a rat model. MATERIALS AND METHODS: For the study, 28-male Sprague-Dawley rats were randomly divided, seven of each, into four groups. Group C (control) received only 0. 9 % NaCl without any drug. Group R received rocuronium alone 1mg/kg. Group S received sugammadex alone 96 mg/kg. Group RS received rocuronium 1mg/kg and sugammadex 96 mg/kg. After 24 h later, the animals were sacrificed and their tissues were removed. Biochemical (IgE/CRP), light microscopic and immunohistochemical findings were recorded. RESULTS: Immunoglobulin E and CRP levels, peribronchial, alveolar septal lymphocytic infiltration, thickening of the alveolar membranes and bleeding sites in Group R were significantly higher than all the other groups. In Group RS, while these parameters were significantly lower than that of Group R and Group S, it was significantly higher than that of Group C. Total mast cells and tryptase-positive mast cells counts were significantly higher in Group R than in all other groups. In Group RS, these parameters were statistically lower than that of Group R and Group S, but higher than that of Group C. CONCLUSIONS: This study shows that allergic inflammatory changes due to rocuronium in the lungs of rats are reduced with sugammadex. These results support cases of anaphylaxis due to rocuronium which improved with sugammadex.

Decompressive craniectomy in traumatic brain injury: Transcranial Doppler sonography used as a guide.

BACKGROUND: Decompressive craniectomy (DC) is performed in the management of intracranial hyper-tension after traumatic brain injury (TBI). This study aims to investigate the effects of transcranial Dop-pler ultrasonography (TCD) measurements on the indication of decompressive surgery. METHODS: Sixteen TBI patients with a Glasgow Coma Score (GCS) <9 were included in this study. Intra-cranial pressure (ICP) monitoring and transcranial Doppler ultrasonography (TCD) measurements were recorded continuously. DC was performed according to the records of ICP and TCD. Glasgow Outcome Scale (GOS) scores were evaluated after three months. RESULTS: Mean age of the patients was 31.18±17.51; GCS ranged between three and 14 with a mean of 9.62±3.95. Mean GOS was 3.12±1.85. Craniectomy was performed in two patients (12.5%) and cra-niectomy and lobectomy together were performed in 14 (87.5%) of them. The decline in ICP (22.12±10.41, 22.62±7.35, 15.50±6.64) and pulsatility index (PI) (1.96±1.10, 1.64±0.75, 1.91±2.48) were strongly significant between days 3-5, and 1-5. The range of PI and Vmax values through five days did not present any significance. CONCLUSION: TCD, as a real-time monitor, may help for an early decision of surgical approach in the management of TBI patients.

The effects of dexmedetomidine and tramadol on post-operative pain and agitation, and extubation quality in paediatric patients undergoing adenotonsillectomy surgery: A randomized trial.

WHAT IS KNOWN AND OBJECTIVE: Adenotonsillectomies are common surgical procedures performed under general anaesthesia in childhood. Post-operative pain and agitation are complications associated with this procedure. We compared the effects of dexmedetomidine and tramadol on post-operative pain, agitation, haemodynamic parameters, and extubation quality in patients undergoing an adenotonsillectomy using sevoflurane as an anaesthetic agent. METHODS: Sixty paediatric patients who had undergone an adenotonsillectomy were included in this study. The patients were randomized into two groups that received either dexmedetomidine (n = 30) or tramadol (n = 30). Haemodynamic variables, extubation time, post-operative pain, agitation and adverse events were recorded for all patients. Post-operative pain was assessed with the pain point system scale (PPSS), and agitation was assessed using the Riker Sedation-Agitation Scale (SAS). RESULTS: Patients in the dexmedetomidine group had significantly lower heart rates than the tramadol group. In addition, patients in the dexmedetomidine group had significantly lower post-operative PPSS and Riker SAS scores than patients in the tramadol group. Not breathing, cough-bucking and desaturation after extubation occurred less frequently in patients who received dexmedetomidine than in patients who received tramadol. However, the time to extubation was significantly longer for patients who received dexmedetomidine. WHAT IS NEW AND CONCLUSION: Our study demonstrated that dexmedetomidine was more effective than tramadol for mitigating post-operative pain and agitation in paediatric patients following an adenotonsillectomy with sevoflurane. Although dexmedetomidine was associated with a longer time to extubation, it was also associated with fewer complications following extubation compared with tramadol.

Comparison of sedation with dexmedetomidine vs propofol during hysteroscopic surgery: Single-centre randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: The most appropriate sedative agent for conscious sedation in minor hysteroscopic surgeries is still unclear. Dexmedetomidine a sedative and analgesic agent, may be appropriate for outpatient procedures. The aim of our study was to compare the sedative, analgesic and hemodynamic effects of dexmedetomidine vs propofol in combination with fentanyl and midazolam in patients undergoing minor hysteroscopy surgery. METHODS: Sixty patients undergoing minor hysteroscopic surgery were randomized to receive either dexmedetomidine (n = 30) or propofol (n = 30) groups. Dexmedetomidine was infused at 1 µg/kg for 10 minutes followed by a 0.7 µg/kg/h maintenance infusion. Propofol was infused a bolus of 1.5 mg/kg followed by a 2.5 mg/kg/h maintenance infusion. Fentanyl 1.5 mcg/kg and midazolam 0.03 mg/kg were performed to all patients as premedication therapy before the hysteroscopic surgery. Post-operative pain score was assessed with visual analogue scale (VAS). Hemodynamic variables and Riker Sedation-Agitation Scale (SAS) scores were recorded for all patients. RESULTS: Mean arterial pressure and heart rate in the dexmedetomidine group were significantly lower than in propofol group, whereas SpO2 was similar between two groups. In addition, post-operative Riker SAS and VAS scores were significantly lower in dexmedetomidine group than in the propofol group. Bradycardia, hypotension and serious adverse events did not occur in any patients. WHAT IS NEW AND CONCLUSION: Dexmedetomidine was associated with better analgesia and lower post-operative pain score than propofol in patients undergoing hysteroscopic surgery. However, arterial pressure and heart rate should be more closely monitored in patients received dexmedetomidine.

Methylene Tetrahydrofolate Reductase Deficiency: the Hidden Risk in Paediatric Anaesthesia.

OBJECTIVE: Methylene tetrahydrofolate reductase (MTHFR) deficiency is an autosomal recessive disorder that results in increased homocysteine levels in the body. Hyperhomocysteinemia causes a predisposition to venous and arterial thrombosis and ischaemic insults. The incidence of the deficiency is around 40% in some countries. In this study, we aimed to evaluate the effects of anaesthetic agents in children with MTHFR deficiency. METHODS: Twelve paediatric patients with an MTHFR enzyme deficiency who underwent surgery in a ten-month period in a single centre were retrospectively evaluated. Demographic data, homocysteine levels before and after surgery, anaesthesia management and postoperative complications were recorded. RESULTS: In four patients, propofol was used both for anaesthesia induction and total intravenous anaesthesia (TIVA). Eight patients received sevoflurane for both induction and maintenance of anaesthesia. Nitrous oxide (N2O) was not used in any patients. There was not a significant difference between the preoperative and postoperative homocysteine levels (p>0.05). Twenty-four hours after the surgery, the homocysteine levels were within normal limits. No complications were observed. CONCLUSION: Sevoflurane and propofol have no deleterious effects on homocysteine levels in patients with MTHFR deficiency. Avoidance of N2O is the key point for anaesthetic consideration regarding these patients.

Epidural anesthesia for pilonidal sinus surgery: ropivacaine versus levobupivacaine.

BACKGROUND: Epidural anesthesia is one of the best options for lower abdominal and lower limb surgery. However, there have been insufficient reports regarding the use of epidural anesthesia for pilonidal sinus surgery. The present study was performed to compare the clinical profiles of epidural block performed with 0.75% levobupivacaine and 0.75% ropivacaine in this procedure. METHODS: Thirty patients undergoing pilonidal sinus surgery were randomly allocated into two groups: one group received levobupivacaine and the other received ropivacaine at 0.75% in a volume of 10 ml. Arterial blood pressure, heart rate, oxygen saturation, the onset time of analgesia and duration of block, highest sensory block level, perioperative and postoperative side effects, and patients' and surgeons' satisfaction were recorded. RESULTS: Hemodynamic stability was maintained in both groups throughout surgery. The onset time of analgesia (the time from epidural injection of local anesthetic to reach L2 sensorial block) was 6.26 ± 3.49 min in the levobupivacaine group and 4.06 ± 1.75 min in the ropivacaine group (P = 0.116). The duration of sensorial block (time for regression of sensory block to L2) was 297.73 ± 70.94 min in group L and 332.40 ± 102.22 min in group R (P = 0.110). Motor block was not seen in any of the patients in the study groups. Patients' and surgeons' satisfaction with the anesthetic technique were mostly excellent in both groups. CONCLUSIONS: In patients undergoing pilonidal sinus surgery, both levobupivacaine and ropivacaine produce rapid and excellent epidural block without leading to motor block or significant side effects. Although not statistically significant, the onset time of anesthesia was shorter and the duration of effect was longer with ropivacaine than with levobupivacaine in this study.

Comparison of recovery profiles of propofol and sevoflurane anesthesia with bispectral index monitoring in percutaneous nephrolithotomy.

BACKGROUND: The aim of the study was to evaluate the comparative effects of propofol infusion versus sevoflurane for maintenance of anesthesia with respect to hemodynamics, recovery characteristics, nausea and vomiting in patients undergoing percutaneous nephrolithotomy. METHODS: Forty American Society of Anesthesiologists physical status I-II patients, aged between 22 and 65 years were randomly divided to receive either intravenous anesthesia with propofol (group P) or sevoflurane (group S). Cardiovascular variables, peripheral oxygen saturation (SpO2), end-tidal carbon dioxide (ETCO2), bispectral index (BIS) and train-of-four (TOF) values were recorded at intervals throughout the procedure. Time to spontaneous respiration, eye opening, extubation, obey commands, hand squeezing, Aldrete Score > 9 and the incidence of postoperative nausea and vomiting were recorded. RESULTS: Early recovery times [spontaneous respiration (P = 0.002), eye opening (P = 0.006), extubation (P = 0.013), obey commands (P < 0.05), hand squeezing (P = 0.005)] were significantly longer in group P. The incidence of vomiting was significantly higher in group S (P < 0.05). Hemodynamic parameters, levels of SpO2, ETCO2, and BIS and TOF values were not significantly different between the groups (P > 0.05). CONCLUSIONS: The present study which adjusted sevoflurane concentration and propofol infusion rate according to BIS values revealed that maintenance of anesthesia with sevoflurane is associated with faster recovery than anesthesia with propofol. Propofol resulted in a significantly lower incidence of postoperative nausea and vomiting. Hemodynamic parameters and levels of SpO2 and ETCO2 were comparable between the groups during percutaneous nephrolithotomy.

Bilateral vocal cord paralysis secondary to head and neck surgery.

Even endotracheal intubation could be considered safe in operations under general anesthesia; rarely, it could cause recurrent laryngeal nerve paralysis as a complication. As mentioned in the literature, as a possible reason for this, anterior branches of the recurrent laryngeal nerve in the larynx could suffer from compression between the posteromedial part of the thyroid cartilage and the cuff of the tube. In the literature, unilateral vocal cord paralysis due to endotracheal intubation occurs more frequently in comparison to bilateral vocal cord paralysis. These types of palsies usually totally improve in approximately 6 months. A patient who experienced bilateral vocal cord paralysis in the early postoperative period after undergoing an endotracheal intubation process for general anesthesia and primary partial lip resection and supraomohyoid neck dissection due to lower lip carcinoma is presented in our article. Although vocal cord paralysis occurring after head and neck surgery is first thought as a complication of the surgery, endotracheal intubation should be considered as a possible cause of this paralysis. In relation with this patient, causes, clinical symptoms, and treatment procedures of vocal cord paralysis due to endotracheal intubation are discussed under guidance of the literature.

A new entity: Chiari Zero malformation and its surgical method.

Recently, Iskandar et al described "Chiari Zero malformation" to characterize some kind of syringomyelia that exhibits classic Chiari-type symptoms with little to no herniation, but there is some dilemma about whether it is actually present. We presented a 38-year-old-man with a diagnosis of cervical syringomyelia. In his neurological examination, there was monoparesia at the left leg together with hypoesthesia below thoracal 7. He had initially been treated with syringopleural shunting successfully. Nine months after surgery, his syringomyelia had regrown and he clinically deteriorated. It was accepted as "a Chiari zero malformation". We performed craniovertebral decompression only. Although there was no tonsillar herniation, his syringomyelia was completely resolved and his neurological status was improved six months after the craniovertebral decompression, This case suggested that "Chiari zero malformation" description is remarkable and craniovertebral decompression is a suitable surgical approach for this entity.

The rate of device-associated nosocomial infections in a medical surgical intensive care unit of a training and research hospital in Turkey: one-year outcomes.

In the present study, we aimed to assess the rate and effect of device-associated nosocomial infections (DANIs), as well as the rate of antibiotic resistance, in the medical-surgical intensive care unit (ICU) of a research and training hospital in Turkey, and to compare our results with those reported by the National Nosocomial Infections Surveillance (NNIS) system and International Nosocomial Infection Control Consortium (INICC). A total of 509 patients were followed up within a 1-year period from 1 November 2007 to 1 November 2008. The total patient days were 4,087, the number of DANIs was 181. The ventilator-associated pneumonia rate in 1,000 ventilator days was 27.1, the rate of central venous catheter (CVC)-associated blood circulation infections in 1,000 CVC days was 11.8, and the rate of urinary catheter-associated urinary tract infections in 1,000 urinary catheter days was 9.6. The most frequently isolated microorganisms were Pseudomonas aeruginosa and Acinetobacter spp. Of the infections caused by Staphylococcus aureus, 81.2% were due to methicillin-resistant strains. Of the Enterobacteriaceae isolates, 53.5% were found to be resistant to ceftriaxone, while 29% of the P. aeruginosa isolates were found to be resistant to ciprofloxacin. The rates of use of devices such as ventilators, CVCs, and urinary catheters were 0.87, 0.93, and 0.98, respectively, which are higher than the rates reported by NNIS and INICC. On the other hand, the present DANI rate was higher than that reported by NNIS, but close to that reported by INICC. We conclude that the indications for and duration of device use should be reviewed.

Moloney darn repair versus lichtenstein mesh hernioplasty for open inguinal hernia repair.

PURPOSE: To compare two tension-free techniques of inguinal hernia repair: the Moloney darn repair (MDR) and Lichtenstein mesh hernioplasty (LMH). METHODS: The subjects of this study were 651 patients from a total 732 who underwent open inguinal herniorrhaphy at our clinic between January 2000 and January 2006. We evaluated and compared analgesic requirement in the first 24 h, operative time, hospital stay, early postoperative complications, time until return to work, and recurrence, between patients who underwent MDR (group A) and patients who underwent LMH (group B). RESULTS: Group B patients required less analgesia in the first 24 h than group A patients. Conversely, the mean operative time and postoperative hospital stay were shorter in group A. Early postoperative complication rates and the time until return to work did not differ significantly between the two groups. During follow-up, recurrences developed in three patients from group A and four from group B. The cost of MDR was significantly less than that of LMH. CONCLUSIONS: Both MDR and LMH resulted in rapid recovery and low recurrence rates; however, the advantage of the MDR lies in the fact that it does not require mesh, so it is much less expensive.