Retrospective Evaluation of the Effect of Lumbar Sympathetic Blockade on Pain Scores, Fontaine Classification, and Collateral Perfusion Status in Patients with Lower Extremity Peripheral Arterial Disease.

Background and Objectives: The aim of this retrospective study was to evaluate the effect of lumbar sympathetic block (LSB) on pain scores, Fontaine Classification, and collateral perfusion status in patients with lower extremity peripheral artery disease (PAD), in whom revascularization is impossible. Material and Methods: Medical records of 21 patients with PAD who underwent LSB with a combination of local anesthetics, steroids, and patient follow-up forms containing six-month follow-ups between January 2020 and March 2021 were retrospectively reviewed. Numeric Rating Scale (NRS), Pain Detect Questionnaire (PDQ) scores, Fontaine Classification Stages, and collateral perfusion status (collateral diameter and/or development of neovascularization) evaluated by arterial color Doppler Ultrasound (US) from the medical records and follow-up forms of the patients were reviewed. Results: NRS and PDQ scores were significantly lower, and regression of the Fontaine Classification Stages was significantly better after the procedure at the first, third, and sixth month than at the baseline values (p < 0.001). Only four patients (19%) had collaterals before the procedure. An increase in the collateral diameter after LSB was noted in three out of four patients. Before the procedure, 17 patients had no prominent collateral. However, in thirteen of these patients, after LSB, neovascularization was detected during the six-month follow-up period (three patients in the first month, seven patients in the third month, and thirteen patients in the sixth month). The number of patients evolving neovascularization after LSB was found to be statistically significant at the third and sixth months compared to the initial examination (p < 0.001). Conclusions: LSB with the use of local anesthetic and steroids in patients with lower extremity PAD not only led to lower NRS and PDQ scores, but also resulted in regressed Fontaine Classification Stages and better collateral perfusion status.

Placenta accreta spectrum surgery with the Joel Cohen incision for abdominal access: a single-center experience.

OBJECTIVES: Placenta accreta spectrum (PAS) is usually treated by hysterectomy performed through a midline incision. We hypothesize that PAS surgery can be performed through a Joel-Cohen incision with adequate sight and safety. MATERIAL AND METHODS: The data on women having a hysterectomy due to PAS between 2013-2021 was collected retrospectively. Operation length, baby's pre-delivery general anesthesia exposure time, transfusion rates, complication rates, postoperative admission to the intensive care unit (ICU), postoperative hospital stay, and neonatal outcomes were collected. In addition, the data investigated whether the operation was performed under emergent conditions and in the early (2013-2016) or late (2017-2021) years. RESULTS: 161 patients met the inclusion criteria. The median gestational age at delivery was 34 weeks (27-39). The mean operation length was 150 minutes (75-420), and the anesthesia-to-delivery interval was 32 minutes (5-95). Twenty-three (14%) patients did not receive any blood product, 73 (45%) received less than three packs of erythrocyte, and only seven (4%) had a massive transfusion. Bladder injuries occurred in 24 (15%). Preoperative anemia, hypogastric artery ligation, transfusion, ICU admission, and maternal and neonatal complications were more frequent in emergent cases. Comparison between the early and late groups showed a decrease in the rate of anemia, maternal ICU admission, hypogastric artery ligation, and neonatal complications. In addition, infectious complications were relatively rare in all groups. CONCLUSIONS: The Joel-Cohen incision and bladder dissection before the baby's delivery reduce transfusion rates and avoid midline incision, which is prone to complications and unpleasant cosmetic appearance while performing a hysterectomy for PAS surgery.

Effects of Ketamine Infusion on Oxygenation in Patients with Chronic Obstructive Pulmonary Disease Undergoing Lung Cancer Surgery.

OBJECTIVE: Ketamine changes respiratory mechanics, provides airway relaxation, and alleviates bronchospasm in patients with pulmonary disease. This study investigated the effect of a continuous infusion of ketamine during thoracic surgery on arterial oxygenation (PaO2/FiO2) and the shunt fraction (Qs/Qt) in patients with chronic obstructive pulmonary disease. METHODS: Thirty patients older than 40 years, diagnosed with chronic obstructive pulmonary disease, and undergoing lobectomy were recruited for this study. Patients were allocated randomly to 1 of 2 groups. At the induction of anaesthesia, group K received intravenous (iv) 1 mg kg-1 ketamine as a bolus and followed by 0.5 mg kg-1 h-1 infusion until the end of the operation. Group S received the same amount of 0.9% saline as a bolus at induction and followed by a 0.5-mL kg-1 h-1 infusion of 0.9% saline until the end of the operation. PaO2 and PaCO2 values, FiO2 levels, PaO2/FiO2 ratio, peak airway pressure (Ppeak), plateau airway pressure (Pplat), dynamic compliance, and shunt fraction (Qs/Qt) were recorded during two-lung ventilation as a baseline and at 30 (one-lung ventilation, OLV-30) and 60 (OLV-60) minutes during one-lung ventilation. RESULTS: PaO2, PaCO2, PaO2/FiO2 values, and Qs/Qt ratio were similar between the 2 groups at OLV-30 minute (P = .36, P = .29, P = .34). However, at OLV-60 minute, PaO2, PaO2/FiO2 values were significantly increased, and Qs/Qt ratios were significantly decreased in group K than in group S (P = .016, P = .011, P = .016). CONCLUSIONS: Our data suggest that a continuous infusion of ketamine and desflurane inhalation in patients with chronic obstructive pulmonary disease during one-lung ventilation increase arterial oxygenation (PaO2/FiO2) and decrease shunt fraction.

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized, controlled study.

STUDY OBJECTIVE: We aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy. DESIGN: A prospective, blinded, randomized, controlled study. SETTING: A tertiary university hospital, operating room and intensive care unit. PATIENTS: Forty children aged 2-10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C). INTERVENTIONS: Group B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia. MEASUREMENTS: The MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded. MAIN RESULTS: Bilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay. CONCLUSION: Ultrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.

Vasopressors for the Treatment and Prophylaxis of Spinal Induced Hypotension during Caesarean Section.

Vasopressors have currently become the mainstay therapy for the management of spinal-induced hypotension (SIH) as the major mechanism of hypotension after spinal anaesthesia is the loss of arteriolar tone produced by sympathetic block. Vasopressors for the prophylaxis and treatment of SIH have been the subject of a significant amount of research, yet remain an attractive and important clinical problem. This review will highlight controversies and recent research on the use of vasopressors for both prophylaxis and treatment of SIH. For decades, ephedrine was considered to be the best vasopressor for the management of maternal hypotension. However, its use has been reported to be associated with a 5-fold increased risk of foetal acidosis than phenylephrine. At present, phenylephrine is the vasopressor of choice for preventing and treating SIH at caesarean section. However, its use is often associated with a decreased heart rate and low cardiac output state owing to the lack of ß-mimetic activity. Norepinephrine has been introduced as an alternative vasopressor for preventing and treating SIH because of its additional ß-mimetic activity. However before its routine clinical use, a further series of studies are needed to establish its efficacy and safety for both the mother and foetus.

Feasibility and rationale of a novel approach in advanced ovarian cancer surgery: Bat- shaped en-bloc total peritonectomy and total hysterectomy salpingo-oophorectomy with or without rectosigmoid resection (Sarta-Bat approach).

OBJECTIVE: To evaluate the feasibility of bat-shaped en-bloc total peritonectomy and total hysterectomy-salpingo-oophorectomy with or without rectosigmoid resection as a novel approach in advanced ovarian cancer surgery. METHODS: Advanced ovarian cancer patients with widespread peritoneal implants requiring total peritonectomy were the subject of the study. Thirteen cases were operated with Sarta-Bat approach between February 2019 and July 2020. Patients' clinical and surgical data were collected and statistically analyzed. RESULTS: Median age of the patients was 52 (40-65). Histopathology of the tumors were high-grade serous carcinoma in 12 (92.3%) and carcinosarcoma in one (7.7%) cases and all of them originated from the ovary. Eight (61.5%), two (15.4%) and three (23.1%) patients were stage 3c, 4a, and 4b, respectively. Upper abdomen was involved in all cases. Nine cases underwent primary cytoreductive and four cases interval cytoreductive surgery. Sarta-Bat approach was performed as en-bloc total peritonectomy, total hysterectomy bilateral salpingo-oophorectomy with rectosigmoid resection in three and without rectosigmoid resection in 10 cases. Final surgery resulted in complete cytoreduction (no macroscopic residual) in all cases, with acceptable grade 2-3 morbidity rates. CONCLUSION: Sarta-Bat approach is a feasible and convenient technique for cytoreductive surgery of advanced ovarian cancer with disseminated peritoneal metastases.

[The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial]. / O efeito de epinefrina, norepinefrina e fenilefrina no tratamento da hipotensão pós­raquianestesia: estudo clínico comparativo.

BACKGROUND AND OBJECTIVES: Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. METHODS: One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 µg.mL-1 (n=40), epinephrine 5 µg.mL-1 (n=40), phenylephrine 100 µg.mL-1 (n=40) or 0.9% saline infusions (n=40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of iv ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. RESULTS: There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p <0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p=0.001). CONCLUSION: There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered as an alternative agent for management of spinal hypotension.

Comparison of the effects of preoperative melatonin or vitamin C administration on postoperative analgesia.

The analgesic benefit of melatonin and vitamin C as primary or adjuvant agents has been reported in various studies; however, their analgesic effects in the treatment of postoperative pain remain unclear. Thus, we aimed to evaluate the effect of single preoperative dose of oral melatonin or vitamin C administration on postoperative analgesia. In this study, we recruited 165 adult patients undergoing elective major abdominal surgery under general anesthesia. Patients were randomly divided into three equal (n = 55) groups. One hour before surgery, patients received orally melatonin (6 mg) in group M, vitamin C (2 g) in group C, or a placebo tablet in group P. Pain, sedation, patient satisfaction, total morphine consumption from a patient-controlled analgesia device, supplemental analgesic requirement, and the incidence of nausea and vomiting were recorded throughout 24 h after surgery. The mean pain score and total morphine consumption were found significantly lower in both M and C groups compared with group P (p < 0.001). There were no significant differences between group M and C with respect to pain scores (p = 0.117) and total morphine consumption (p = 0.090). Patients requested less supplemental analgesic and experienced less nausea and vomiting in groups M and C compared with group P. In conclusion, preoperative oral administration of 6 mg melatonin or 2 g vitamin C led to a reduction in pain scores, total morphine consumption, supplemental analgesic requirement, and the incidence of nausea and vomiting compared with placebo.

The relationship between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients.

OBJECTIVES: The purpose of the study was to evaluate any comorbid psychiatric disorders in patients with chronic pain and to examine the effects of sociodemographic details and the level of somatic sense perception on the severity of these diseases. METHODS: In this study, 51 chronic pain patients were evaluated in a consultation with a psychiatrist. Sociodemographic characteristics of the patients, such as age, gender, education level, and marital status were recorded, and Structured Clinical Interview for DSM-IV results were assessed. The patients' chronic pains were classified as idiopathic or secondary to organic etiology. In addition, the Symptom Checklist-90, Somatosensory Amplification Scale (SSAS), Hamilton Depression Rating Scale, and the Hamilton Anxiety Scale (HAM-A) were used. RESULTS: The incidence of psychiatric disorders in chronic pain patients was found to be 74.5%. Somatoform disorders were the most frequently diagnosed, at 37.3%. The rate of depressive and anxiety disorders was, respectively, 29.4% and 23.5%. Comorbid anxiety scores (p=0.019) and SSAS scores (p=0.046) were significantly higher in chronic pain patients with a somatoform disorder. HAM-A scores were found to be significantly higher in patients with depression (p=0.004). A positive and linear relationship was determined between the SSAS score and depression, anxiety, and the severity of mental symptoms. CONCLUSION: Structured or semi-structured interviews can be performed in pain polyclinics or psychiatric outpatient clinics to determine the level of perception of somatic sensations. This could be beneficial in the treatment of chronic pain and comorbid psychiatric disorders.

Comparison of the Effects of Epidural Levobupivacaine with Tramadol or Morphine Addition on Postoperative Analgesia following Major Abdominal Surgery.

OBJECTIVE: The study was designed to compare the postoperative analgesic efficacy of epidural tramadol or epidural morphine as adjuvant to levobupivacaine in major abdominal surgery. METHODS: Patients in ASA I-II group aged between 18 and 65 years were included in study. Epidural catheter was introduced. Patients were randomised into three groups to receive levobupivacaine (Group L), levobupivacaine+morphine (Group LM) and levobupivacaine+tramadol (Group LT). General anaesthesia was administered to all patients. The solution intended for Group L contained 25 mg 0.5% levobupivacaine+15 mL saline, that for Group LM contained 25 mg 0.5% levobupivacaine+14.5 mL salin+100 µg morphine and that for Group LT contained 25 mg 0.5% levobupivacaine+13 mL salin+100 mg tramadol, which was administered via epidural catheter as loading dose 30 min before the end of the operation. Patient-controlled analgesia device was connected to the epidural catheter to provide postoperative analgesia. Bolus dose was adjusted to 12 mg levobupivacaine in Group L, 12 mg levobupivacaine +1.2 mg morphine in Group LM and 12 mg levobupivacaine+12 mg tramadol in Group LT. Lock-out period was adjusted to 15 min in three groups. Quality of analgesia was evaluated using Visual Analogue Scale; administered and demand doses of levobupivacaine, morphine and tramadol were compared at 30 min, 1, 2, 6, 12 and 24 h postoperatively. RESULTS: Visual Analogue Scale scores were significantly higher in Group L than Groups LM and LT. Nausea and vomiting observed in Group L were lesser than those in Groups LM and LT. CONCLUSION: Continuous epidural analgesia using levobupivacaine combined with morphine or tramadol is an effective method for managing postoperative analgesia in major abdominal surgery.

Retrospective Analysis of Eighty-Nine Caesarean Section Cases with Abnormal Placental Invasion.

OBJECTIVE: Abnormal placental invasion (API) is defined as an abnormal adherence of the placenta to the underlying uterine wall. Undiagnosed API may result in catastrophic maternal haemorrhage during delivery. In the present retrospective analysis, anaesthetic and surgical records were evaluated in patients with API who had undergone caesarean delivery (CD). METHODS: Clinical records of 89 patients with API who had undergone CD were retrospectively reviewed in our clinic between April 2010 and February 2017. RESULTS: Amongst the patients, 87 (97.8%) had a history of previous CD and 68 (76.4%) had placenta previa. In regression analysis, weak positive correlation was found between an increase in packed red blood cell (PRBC) (r=0.420, p=0.001) and fresh frozen plasma (FFP) (r=0.476, p=0.022) transfusions and time of hospital stay. PRBC and FFP consumptions were significantly greater in intensive care unit (ICU) patients than in non-ICU patients (p<0.001). ICU requirement were significantly greater in patients who had more than average crystalloid (p=0.004) and colloid (p<0.001) infusions. Elective CD was performed in 81 (91%) patients and emergency CD in 8 (9%). PRBC transfusions were 7±4.3 U in patients undergoing emergency CD and 3.85±3 U in patients undergoing elective CD (p=0.034). The number of patients requiring care in ICU was 4 (50%), who underwent emergency CD and 12 (14%) who underwent elective CD, (p=0.032). CONCLUSION: It is crucial that the anaesthesiologist should be familiar with the risk factors and diagnosis of API because of the potential risk of massive haemorrhage. Multidisciplinary approach with surgery and blood bank decreases the amount of bleeding, blood transfusion requirement, ICU and hospital stay in patients with API.

Does prophylactic ondansetron reduce norepinephrine consumption in patients undergoing cesarean section with spinal anesthesia?

PURPOSE: Spinal anesthesia-induced hypotension (SAIH) during cesarean delivery is not rare and frequently leads to materno-fetal discrepancy and collapse. More recently, norepinephrine has been proposed for the prevention and treatment of SAIH with fewer tendencies to decrease heart rate and cardiac output. Ondansetron has been reported to reduce the incidence of SAIH in patients undergoing cesarean section. The aim of the present study was to assess the effect of prophylactic ondansetron on the incidence of SAIH, norepinephrine consumption, and adverse effects. METHODS: We recruited 108 parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia. The parturients were divided into two groups randomly. The first group (n = 54) received 8 mg ondansetron IV (group O) and the second group (n = 54) received the same volume (4 ml) of saline (group S), 5 min before spinal anesthesia. The incidence of hypotension, cumulative episodes of hypotension, total norepinephrine consumption, and adverse effects were recorded. RESULTS: There was no significant difference between the two groups in demographic data, parturient characteristics, and duration of surgery. No significant difference was found in the incidence of hypotension in the saline and ondansetron groups (p = 0.767). However, the cumulative episodes of hypotension and norepinephrine consumptions were significantly greater in group S than in group O (p = 0.009) (p = 0.009). There was also no significant difference in the incidence of adverse effects between the two groups. CONCLUSION: Eight milligrams of intravenous ondansetron given 5 min before spinal anesthesia attenuated but did not prevent spinal anesthesia-induced hypotension in parturients undergoing elective cesarean delivery.

Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain: Comparison of monopolar and bipolar modes.

OBJECTIVES: Radiofrequency thermocoagulation (RFT) has been reported to be used safely to treat ischemic lower extremity pain. The objective of the present study was to evaluate efficiency of RFT for treatment of lower extremity ischemic pain and to compare effectiveness of monopolar RFT and bipolar RFT modes. METHODS: Following ethics committee approval, 30 American Society of Anesthesiologists classification I-III patients with ischemic lower extremity pain aged between 18 and 65 years were recruited. Patients were randomly allocated into 2 groups: MRT group (n=15) received monopolar RFT (80°C) for 2 minutes at L2-3 level, and BRT group (n=15) received bipolar RFT (80°C) for 2 minutes at L2-3 level. Systolic and diastolic blood pressure, heart rate, pain score, and supplemental analgesic requirements were recorded at 24 hours after application and at 7, 30, and 90 days. RESULTS: Numerical rating scale values in both groups decreased significantly over time and it was found to be significantly lower in BRT group after first and third months (p<0.05). Supplemental analgesic requirements were similar with no significant difference between the 2 groups at any point of study period (p>0.05). No adverse event or complication related to procedure or treatment was reported. CONCLUSION: In patients with ischemic lower extremity pain, both monopolar and bipolar RFT treatment modalities were found to significantly decrease pain levels. However, bipolar mode led to lower pain scores at 30 and 90 days, and longer duration of analgesia than monopolar mode.

The Effect of Intravenous Dexamethasone on Sugammadex Reversal Time in Children Undergoing Adenotonsillectomy.

BACKGROUND: Dexamethasone has been shown to cause inhibition of sugammadex reversal in functionally innervated human muscle cells. In this prospective, double-blind, randomized, controlled study, we evaluated the effect of dexamethasone on the reversal time of sugammadex in children undergoing tonsillectomy and/or adenoidectomy. METHODS: We recruited 60 patients with ASA physical status I to II, between the ages of 3 and 8 years, scheduled for elective tonsillectomy and/or adenoidectomy. After the induction of anesthesia, patients in group D received IV dexamethasone at a dose of 0.5 mg/kg within a total volume of 5 mL saline, whereas patients in group S received only 5 mL IV saline as the control group. At the end of surgery, all patients were given a single bolus dose (2 mg/kg) of sugammadex at reappearance of T2. Demographic data, hemodynamic variables, time to recovery (a train-of-four ratio of 0.9), time to tracheal extubation, and adverse effects were recorded. RESULTS: There was no statistical significance between 2 groups in time to recovery and time to extubation. Time to recovery was 97.7 ± 23.9 seconds in group D and 91.1 ± 39.5 seconds in group S (P = 0.436; 95% confidence interval, -10.3 to 23.5). Time to extubation was 127.9 ± 23.2 seconds and 123.8 ± 38.7 seconds in group D and in group S, respectively (P = 0.612; 95% confidence interval, -11.9 to 20.05). CONCLUSIONS: IV dexamethasone, given after induction of anesthesia, at a dose of 0.5 mg/kg, does not substantively affect the reversal time of sugammadex in pediatric patients undergoing adenoidectomy and/or tonsillectomy.

Coadministration of intravenous remifentanil and morphine for post-thoracotomy pain: comparison with intravenous morphine alone.

OBJECTIVES: In this double-blind, randomized study, the authors compared the effects of a patient-controlled remifentanil and morphine combination with morphine alone on post-thoracotomy pain, analgesic consumption, and side effects. DESIGN: A prospective, randomized, double-blind clinical study. SETTING: University hospital. PARTICIPANTS: Volunteer patients at a university hospital undergoing elective thoracotomy surgery. INTERVENTIONS: Patients were allocated randomly into 2 groups to receive patient-controlled analgesia: the morphine (M) group or the morphine plus remifentanil (MR) group. Pain, discomfort, sedation scores, cumulative patient-controlled morphine consumption, rescue analgesic (meperidine) requirement and side effects were recorded for 24 hours. MEASUREMENTS AND MAIN RESULTS: Sixty patients were allocated randomly to receive intravenous patient-controlled analgesia with morphine alone (M) or morphine plus remifentanil (MR) in a double-blind manner. Patients were allowed to use bolus doses of morphine (0.02 mg/kg) or the same dose of a morphine plus remifentanil (0.2 µg/kg) mixture every 10 minutes without a background infusion. VAS scores were lower in the MR group than in the M group at 30 minutes (p = 0.04), 1 hour (p = 0.03), and 2 hours (p = 0.04). Mean cumulative doses of morphine were not significantly different at 27.8±15 mg for the M group and 21.9±10.5 mg for the MR group. Significantly more patients needed meperidine in the M group (p = 0.039); these also experienced more nausea (p = 0.01). CONCLUSIONS: Coadministration of PCA remifentanil with morphine for the treatment of post-thoracotomy pain did not reduce morphine consumption but provided superior analgesia, less use of rescue analgesics, and fewer side effects compared to morphine alone.

The Effect of Intravenous Magnesium Sulphate Treatment on the Spinal Anaesthesia Produced by Bupivacaine in Pre-eclamptic Patients.

OBJECTIVE: In our study, the effect of intravenous magnesium sulphate in normal and pre-eclamptic patients on spinal anaesthesia produced by bupivacaine was investigated. METHODS: Sixty-four pregnant (32 normal and 32 pre-eclamptic) were accepted in this study. Pregnants were divided into four groups as patients given intravenous magnesium sulphate and as control. Spinal anaesthesia was induced with 12.5 mg 0.5% hyperbaric bupivacaine. Intraoperative and postoperative haemodynamic variables, sensorial block periods, onset times of sensorial and motor block, maximum sensorial block levels, the time to reach maximum block level, Bromage scores, consumptions of intraoperative analgesic and ephedrine, the quality of anaesthesia, the duration of spinal anaesthesia and magnesium levels in blood and cerebrospinal fluid were measured and recorded. RESULTS: The level of magnesium in blood and cerebrospinal fluid was significantly higher in the group given magnesium in pre-eclamptic patients (p<0.01). Onset of sensory block times were significantly longer in intravenous magnesium group than in groups 1, 2 and 3 (p<0.05). Onset of motor block times were significantly longer and the duration of anaesthesia was shorter in groups given magnesium (p<0.05). Although the quality of anaesthesia was similar, supplemental analgesic consumption was significantly higher in pre-eclamptic pregnants given magnesium sulphate than in pre-eclamptic pregnants who were not given magnesium sulphate (p<0.05). CONCLUSION: Intravenous magnesium sulphate treatment during the spinal anaesthesia produced by bupivacaine extended the onset of sensory and motor block times, shortened the duration of spinal anaesthesia and therefore led to early analgesic requirement.

A Comparative Study of the Efficacy of IV Dexketoprofen, Lornoxicam, and Diclophenac Sodium on Postoperative Analgesia and Tramadol Consumption in Patients Receiving Patient-Controlled Tramadol.

OBJECTIVE: This study was designed to compare the effects of dexketoprofen, lornoxicam, and diclophenac sodium on postoperative analgesia and tramadol consumption in patients receiving postoperative patient-controlled tramadol after a major abdominal surgery. METHODS: Eighty patients were randomized to receive one of the four study drugs. Patients in group dexketoprofen (DT) received IV 50 mg dexketoprofen, group lornoxicam (LR) received IV 8 mg lornoxicam, group diclophenac sodium (DS) received 75 mg IV diclophenac sodium and group saline (S) received 0.9% saline in 2 mL syringes, 20 min before the end of anaesthesia. A standardized (1 mg kg(-1)) dose of tramadol was routinely administered to all patients as the loading dose at the end of surgery. Postoperatively, whenever patients requested, they were allowed to use a tramadol patient-controlled analgesia device giving a bolus dose (0.2 mg kg(-1)) of tramadol. Pain, discomfort, and sedation scores, cumulative tramadol consumption, supplemental meperidine requirement, and side effects were recorded. RESULTS: Visual rating scale and patient discomfort scores were significantly lower in DT, LR and DS groups compared to those in in group S (p<0.001). Cumulative tramadol consumption was significantly lower in non-steroidal anti-inflammatory drug (NSAID)-treated groups at each study period after the second postoperative hour than in group S (p<0.001). Supplemental meperidine requirement was significantly higher in group S at each study period after postoperative 30 min than in NSAID-treated groups (p<0.01). CONCLUSION: After major abdominal surgery, adding IV diclophenac, lornoxicam or dexketoprofen to patient-controlled tramadol resulted in lower pain scores, smaller tramadol consumption, less rescue supplemental analgesic requirement, and fewer side effects compared with the tramadol alone group.

RAPID FLUID ADMINISTRATION AND THE INCIDENCE OF HYPOTENSION INDUCED BY SPINAL ANESTHESIA AND EPHEDRINE REQUIREMENT: THE EFFECT OF CRYSTALLOID VERSUS COLLOID COLOADING.

PURPOSE: Spinal anesthesia for caesarean delivery is often associated with hypotension. This study was conducted to evaluate the effects of rapid crystalloid (Lactated Ringer's solution; LRS) or colloid (hydroxyethyl starch; HES) cohydration with a second intravenous access line on the incidence of hypotension and ephedrine requirement during spinal anesthesia for cesarean section. METHODS: We studied 90 women with uncomplicated pregnancies undergoing elective cesarean section under spinal anesthesia. Intravenous access was established in all patients with two peripheral intravenous lines, the first being used for the baseline volume infusion. Immediately after induction of spinal anesthesia, LRS (Group L) or HES (Group C) infusions were started at the maximal possible rate via the second line in groups L and C respectively. In the third group (Group E), patients received lactated Ringer's solution at a 'keep vein open' rate to maintain the double-blind nature. The incidence of hypotension, ephedrine requirements, total amount of volume and side effects were recorded. RESULTS: The incidence of hypotension was significantly greater in group E than in groups L and C, and greater in group L than in group C (p < 0.03 and p < 0.01 respectively ). The total dose of ephedrine used to treat hypotension was significantly less in groups L and C than in group E (p < 0.001 and p < 0.001 respectively). Groups L and C received similar infusion volumes and doses of ephedrine. CONCLUSIONS: Giving either LR or HES coloading via a second IV line caused less hypotension and required less use of ephedrine compared to no coloading. There were no maternal or neonatal side effects.

The Comparison of Patient-Controlled Remifentanil Administered by Two Different Protocols (Bolus and Bolus+Infusion) and Intramuscular Meperidine for Labor Analgesia.

OBJECTIVE: Nowadays, there are many pain relief methods for reducing the pain and stress of labor and delivery. In our study, two different remifentanil protocols (bolus and bolus+infusion) administered by patient-controlled analgesia method were compared with intramuscular meperidine for labor analgesia. METHODS: Ninety parturients who were scheduled for vaginal delivery were included in this study. Patients were randomly divided into 3 groups, with 15 primiparous and 15 multiparous patients in each group. Whenever a patient requested analgesics during the labor, Group M was given 1 mg kg(-1) intramuscular meperidine, Group B was given intravenous bolus patient-controlled remifentanil, and Group IB was given intravenous bolus+infusion patient-controlled remifentanil. Patients' systolic and diastolic blood pressure, heart rate, pain-comfort and sedation scores, remifentanil consumption, side effects, and Apgar scores of the newborns were evaluated during the labor and delivery. RESULTS: Patients' mean pain and comfort scores were significantly lower in Groups B and IB than in Group M at all time intervals except the first minute. Compared with Group IB, mean pain and comfort scores at 15, 30, 60, and 120 minutes were significantly higher in Group B. The mean sedation scores were similar among the groups. Total remifentanil consumption was lower in Group IB than in Group B, but it was not statistically significant. CONCLUSION: Patient-controlled intravenous bolus or bolus+infusion remifentanil provided more effective analgesia and patient comfort than intramuscular meperidine for labor analgesia. Especially during labor, bolus+infusion remifentanil administration provided better pain and patient comfort scores than bolus alone, without increasing remifentanil consumption.

Do all deliveries with elective caesarean section need paediatrician attendance?

AIM: To determine whether paediatrician attendance to deliveries with elective caesarean section (CS) is really needed for term and also for preterm babies with 35-37 weeks gestational age. METHODS: Singleton newborns ≥35 gestational weeks without any identified risk factor were evaluated for resuscitation steps prospectively after CS under regional and general anaesthesia. RESULTS: 545 infants were included in the study. 150 (27.5%) of infants needed only supplemental oxygen and 23 (4.2%) neonates needed bag and mask ventilation. None of the babies needed cardiopulmonary resuscitation (CPR) (chest compression) or endotracheal tube insertion/epinephrine administration. More infants required supplemental oxygen and bag-mask ventilation in general anaesthesia delivery group compared to spinal/epidural anaesthesia group (35.5% vs. 24.4%, p = 0.29 for oxygen and 9.2 % vs. 2.3%, p < 0.0001 for bag-mask) The need for resuscitation steps was not statistically significantly different between neonates who were born in 35-37 gestational week and neonates who were born ≥38 week (p = 0.170 for supplementary oxygen, p = 0.442 for bag-mask ventilation). CONCLUSION: There is not increased risk for chest compression and entubation for infants ≥ 35 gestation weeks without antenatally identified risk factors born with elective CS either under regional or general anesthesia and only 4.2% of the babies needed bag-mask ventilation, so a health care personel who knows basic NRP may be sufficient in the clinics where it is easy to achieve an advanced skilled health care personel when needed.