Association of postpartum depression and epidural analgesia in women during labor: an observational study.

BACKGROUND AND OBJECTIVES: Postpartum depression affects women, manifesting with depressed mood, insomnia, psychomotor retardation, and suicidal thoughts. Our study examined if there is an association between epidural analgesia use and postpartum depression. METHODS: Patients were divided into two groups. One group received epidural analgesia during labor while the second group did not. The Edinburgh postnatal depression scale (EPDS) was administered to patients prior to birth and 6 weeks postpartum. Pain severity was assessed by the Visual Analogue Scale (VAS) during labor and at 24hours postpartum. RESULTS: Of the 92 patients analyzed, 47.8% (n=44) received epidural analgesia. We detected significantly higher VAS score during labor (p= 0.007) and 24 hours postpartum (p = 0.0001) in the group without epidural analgesia. At 6 weeks postpartum, a significant difference was observed between the EPDS scores of both groups (p= 0.0001). Regression analysis revealed higher depression scores in patients experiencing higher levels of pain during labor (OR = 0.572, p= 0.039). Epidural analgesia strongly correlated with lower scores of depression (OR = 0.29, p= 0.0001). CONCLUSION: The group that received epidural analgesia had lower pain scores. A high correlation between epidural analgesia and lower depression levels was found. Pregnant women giving birth via the vaginal route and having high pain scores could reduce postnatal depression scores using epidural labor analgesia. Pregnant women should opt for epidural analgesia during labor to lessen postpartum depression levels.

Comparison of treatment outcomes in lumbar central stenosis patients treated with epidural steroid injections: interlaminar versus bilateral transforaminal approach.

BACKGROUND: We aimed to compare interlaminar epidural steroid injections (ILESI) and bilateral transforaminal epidural steroid injections (TFESI) on pain intensity, functional status, depression, walking distance, and the neuropathic component in patients with lumbar central spinal stenosis (LCSS). METHODS: The patients were divided into either the ILESI or the bilateral TFESI groups. Prime outcome measures include the numerical rating scale (NRS), Oswestry disability index (ODI), Beck depression inventory (BDI), and pain-free walking distance. The douleur neuropathique en 4 questions score was used as a secondary outcome measure. RESULTS: A total of 72 patients were finally included. NRS, ODI, and BDI scores showed a significant decline in both groups in all follow-ups. Third-month NRS scores were significantly lower in the ILESI group (P = 0.047). The percentages of decrease in the ODI and BDI scores between the baseline and the third week and third month were significantly higher in the ILESI group (P = 0.017, P = 0.001 and P = 0.048, P = 0.030, respectively). Pain-free walking distance percentages from the baseline to the third week and third month were significantly higher in the ILESI group (P = 0.036, P < 0.001). The proportion of patients with neuropathic pain in the bilateral TFESI group significantly decreased in the third week compared to the baseline (P = 0.020). CONCLUSIONS: Both ILESI and TFESI are reliable treatment options for LCSS. ILESI might be preferred because of easier application and more effectiveness. However, TFESI might be a better option in patients with more prominent neuropathic pain.

Are Foraminal Stenosis Severity and Herniation Level Associated with the Treatment Success of Cervical Interlaminar Epidural Steroid Injection?

BACKGROUND: Foraminal stenosis, defined as a narrowing of the cervical neural foramen, is one of the most common causes of upper extremity radicular pain. OBJECTIVES: The aim of our study was to determine the effects of the severity of neural foraminal stenosis and spinal herniation level on treatment success in patients treated with interlaminar epidural steroid injections (ILESI) due to cervical disc herniation-related radiculopathy and their possible predictive roles. STUDY DESIGN: A retrospective assessment. SETTING: A university hospital interventional pain management center. METHODS: We performed our study between August 2017 and February 2019, retrospectively. All patients' demographic characteristics, clinical and demographic data, including pain scores before and after cervical ILESI in the first hour, third week, and third month follow-ups, presence of motor deficits, symptom side, symptom duration before cervical ILESI, and whether there was progression to surgery in the 3-month period after injection, were collected. RESULTS: We evaluated 61 patients in the final analysis. When the spinal herniation levels and foraminal stenosis grades were compared, there was a significant difference between the groups (P = 0.003, P = 0.005). We reported significant correlations between foraminal stenosis grade (odds ratio [OR], -0.425, P = 0.038) and spinal herniation level (OR, -0.925, P = 0.001) and treatment success. LIMITATIONS: Our study's design was retrospective. CONCLUSIONS: Cervical ILESI is a reliable treatment option that provides a significant reduction in pain of patients with cervical radiculopathy. However, the success of ILESI treatment may be negatively affected in these patients in the presence of high spinal level cervical disc herniation and severe foraminal stenosis. Therefore considering these 2 parameters in predicting the patient population who will benefit from cervical ILESI is of importance in terms of decreasing potential complications. KEY WORDS: Interlaminar epidural steroid injections, foraminal stenosis, spinal level, cervical disc herniation, radicular pain.

The effect of intravenous tranexamic acid on visual clarity during arthroscopic rotator cuff repair: A randomized, double-blinded, placebo-controlled pilot study.

OBJECTIVE: The aim of this study was to determine the effect of intravenous (IV) tranexamic acid (TRX) use on visual clarity during arthroscopic rotator cuff repair. METHODS: This prospective, randomized, double-blinded, placebo-controlled study was conducted in patients scheduled for an arthroscopic rotator cuff repair. In total, 60 patients were randomly distributed into two groups: control (28 patients: 11 male, 17 female; mean age=53 years, age range=19-65) and TRX (32 patients: 15 male, 17 female; mean age=50, age range=18-69). In the TRX group, the arthroscopy was performed through the bolus IV administration of 10 mg/kg TRX in 100 ml isotonic saline solution. In the control group, the arthroscopy was performed through the bolus IV administration of 100 ml isotonic saline solution. In both the groups, the IV administration was carried out after the induction of anesthesia. At the end of each procedure, the surgeon rated the visual clarity on a scale from 1 to 10. In addition, operation time (minutes), irrigation amount used in operation (lt), and the need of pressure increase because of bleeding were recorded. RESULTS: No adverse effects were seen during the study period. Visual clarity in TRX group was significantly better than the control group (the mean visual clarity scores=8.1/10 (range=7-10) vs 7/10 (range=5-9); p=0.018). The amount of solution was significantly less in the TRX group (10.2 lt (range=3.5-21)) than in the control group (15.8 lt (range=5.8-27); p=0.007, post-hoc power=95.7%), although the operation time was slightly longer in the TRX group (106 minutes (range=50-210)) than in the control group (99 minutes (range=45-165); p=0.24). Moreover, the need for the increase in pressure owing to bleeding was found significantly less in the TRX group (5.8 times (range=(0-9)) than in the control group (9.6 times (range=0-13); p=0.04, post-hoc power=94.5%). CONCLUSION: Preoperative IV TRX administration seems to be effective in improving visual clarity and reducing the need for high pressure and the amount of irrigation fluid during the arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: Level II, Therapeutic study.

Are steroids required in the treatment of ganglion impar blockade in chronic coccydynia? a prospective double-blinded clinical trial.

BACKGROUND: Ganglion impar blockade is a reliable and effective treatment option used in patients with coccydynia. Our primary objective was to specify the role of corticosteroids in impar blockade. We compared applications of local anesthetic with the local anesthetic + corticosteroid combination in terms of treatment efficiency in patients with chronic coccydynia. METHODS: Our study was a prospective randomize double-blind study. The patients were divided into 2 groups after randomization. The first group (group SL) was made up of patients where a corticosteroid + local anesthetic were used during ganglion impar blockade. In the second group (group L) we used only local anesthetic. We evaluated numeric rating scale (NRS) and Beck depression scale, which were employed before the procedure and in 1st and 3rd months after the procedure. RESULTS: Seventy-three patients were included in the final analysis. We detected a significantly greater decrease in NRS values in the 1st month in group SL than in group L (P = 0.001). In the same way, NRS values in the 3rd month were significantly lower in the group with steroids (P = 0.0001). During the evaluation of the Beck test, we detected significantly greater decreases in the 1st month (P = 0.017) and 3rd month (P = 0.021) in the SL group than in the L group. CONCLUSIONS: Ganglion impar blockade decreases pain in the treatment of chronic coccydynia and improve depression. Addition of steroids in a ganglion impar blockade is required for treatment response that should accumulate over a long period of time.

Does Coadministration of Transforaminal Epidural Steroid Injection with Sedation Improve Patient Satisfaction? A Prospective Randomized Clinical Study.

BACKGROUND: Transforaminal epidural steroid injection (TFESI) can be administered with or without sedation in clinical practice. OBJECTIVES: The aim of this study was to compare both procedures in terms of patient and physician satisfaction, preoperative anxiety level, procedural pain level, and complications. STUDY DESIGN: A prospective randomized trial. SETTING: A university hospital interventional pain management center. METHODS: The study included patients scheduled for single-level unilateral TFESI. The patients were randomized into 2 groups. The first group underwent TFESI without sedation, whereas the second group underwent TFESI with sedation. The Likert scale was used to determine the patient and physician satisfaction, and the Numeric Rating Scale (NRS-11) was used to determine the procedural pain level. Cases in which the procedure was to be repeated, the patient was questioned if they desired to undergo the procedure with the same technique. RESULTS: A total of 64 patients, (31 [48.4%] in the sedation group) were included. In the sedation group, the patient and physician satisfaction were significantly higher (P = 0.0001), the periprocedural NRS-11 scores were significantly lower (P = 0.0001), and the rate of desire to have the intervention with the same technique was higher (P = 0.001). After the regression analysis, we reported that there was a significant correlation between being in the sedation group and NRS-11 procedure scores, the desire to have the same technique, and patient and physician satisfaction (odds ratio [OR], 0.341; OR, 0.648; OR, 0.329; OR, 0.514; P = 0.0001). LIMITATIONS: Both patients and physicians were unblinded. CONCLUSIONS: Coadministration of TFESI with sedation improves patient and physician satisfaction. Additionally, the low periprocedural pain level results in patients' demand for the intervention to be performed with sedation in the event of repetition of the procedure. KEY WORDS: Patient satisfaction, transforaminal epidural steroid injection, sedation, physician satisfaction.

The association between the APACHE-II scores and age groups for predicting mortality in an intensive care unit: a retrospective study.

BACKGROUND AND AIMS: In this study, we aimed to evaluate whether the age or the APACHE-II score was a better predictor of mortality in each group. The secondary objective was to investigate the factors affecting the mortality in each individual age group. METHODS: We designed this retrospective study between 2016-2017. Age groups were classified into 3 classes: Patients < 60 years were Group 1, patients between 60-70 years were Group 2, and patients > 70 years were Group 3. We recorded patients' age, ICU indication, demographic data, APACHE-II, ASA, length of hospital stays and mortality. RESULTS: We analysed 150 patients and reported mortality for 58 patients (38.7%). We did not detect any association between age and mortality for all groups. ASA, length of ICU stays and predicted mortality rate, were significantly higher for exitus patients (p < 0.001). The ROC curve for the APACHE-II score, with a cut-off point of 23, demonstrated 74.14% sensitivity, 60.87% specificity, an area under the curve (AUC) of 67.3%, with 4.5% standard deviation (SD). The ODDS ratio for APACHE-II scores was 4.459 (95% CI: 2.167-9.176). For the adjusted mortality rate, ROC analysis identified a cut-off of 60.8 with 70.69% sensitivity, 52.17% specificity, AUC of 61.2% and 4.6% SD. The ODDS ratio for the adjusted mortality rate was 2.631 (95% CI: 1.309-5.287). CONCLUSION: We could not demonstrate any correlation between age and mortality. We consider APACHE-II as a valuable scoring system to predict mortality. We do not consider age as a predictor of mortality. Therefore, we do not suggest its use as a sole prognostic marker in ICU patients.

Effect of anaesthetic technique on neonatal morbidity in emergency caesarean section for foetal distress.

BACKGROUND: While foetal distress is typically associated with ischaemic injury, few studies have assessed neonatal morbidity for emergency caesarean section. Moreover, the decision of the anaesthetic technique may be of paramount importance in emergency caesareans, because of the limited time and increased risk. We aimed to evaluate the effect of the anaesthetic technique on neonatal morbidity in emergency caesarean indicated for foetal distress. METHODS: This was a single-centre, prospective observational study, conducted between July-2015 and December-2015. The study enrolled parturient with indication for emergency caesarean section after diagnosis of foetal distress, who received either regional or general anaesthesia. The outcome measures were: 1, 5-minute Apgar scores; umbilical blood pH; length of hospitalization; and morbidity, defined as a 5-minute Apgar score <7, need for mechanical ventilation, admittance to a neonatal intensive care unit, or respiratory insufficiency symptoms. RESULTS: 61 patients were included in the study, of whom 31 received regional anaesthesia. Neonatal morbidity was noted in 5 and 9 cases with regional and general anaesthesia, respectively. The 1-minute Apgar score was significantly lower(p = 0,045) for cases with general anaesthesia, which was not true for the 5-minute Apgar score. Regional anaesthesia was non-significantly associated with shorter length of hospitalization, lower incidence of morbidity, and higher umbilical blood pH. When we take regional anaesthesia cases as a reference point, we detected that general anaesthesia cases are showing 2,2 times more morbidity risk. But these results did not reach any statistically significant levels. CONCLUSIONS: While we did find some improved results for regional anaesthesia group, we found no statistical evidence that neither anaesthesia technique is superior regarding neonatal morbidity. We think that regional anaesthesia should be preferred whenever possible because of our improved results of length of hospital stay, APGAR and morbidity and we think that general anaesthesia is indicated for very urgent cases or regional anaesthesia contraindicated patients. TRIAL REGISTRATION: http://www.isrctn.com/ISRCTN15181117.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia

Abstract Background and objectives: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. Methods: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients’ internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5 min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4) min. Results: There was a significant decrease between T0 and T1 in heart rate (80.5 ± 11.6 vs. 75.9 ± 14.4 beats/min), MAP (105.8 ± 21.9 vs. 78.9 ± 18.4 mmHg) and PSI (88.5 ± 8.3 vs. 30.3 ± 9.7) (all p < 0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. Conclusion: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20 min.

Resumo Justificativa e objetivos: Demonstrar as possíveis alterações hemodinâmicas e do fluxo sanguíneo cerebral (FSC) em pacientes que foram posicionados de supinação para cadeira de praia (CP) e detectar se a mudança de posição causa alguma alteração na atividade cortical como mensurado pelo monitor de EEG com quatro canais. Métodos: Foram incluídos 35 pacientes. Antes da indução, os valores da PAM e do IEP foram registrados (T0). Após a intubação, ultrassonografias com Doppler da carótida interna e artérias vertebrais dos pacientes foram avaliadas para adquirir os valores do FSC a partir da fórmula. Em supinação, os valores da PAM, IEP e FSC foram registrados (T1) e o paciente foi posicionado em CP. Após cinco minutos, todas as mensurações foram repetidas (T2). As mensurações do IEP e PAM foram repetidas após 20 (T3) e 40 minutos (T4). Resultados: Houve uma diminuição significativa entre T0 e T1 na FC (80,5 ± 11,6 vs. 75,9 ± 14,4 bpm), PAM (105,8 ± 21,9 vs. 78,9 ± 18,4 mmHg) e IEP (88,5 ± 8,3 vs. 30,3 ± 9,7) (p < 0,05 para todos). A PAM diminuiu significativamente após a mudança de posição e permaneceu diminuída em relação a T1. A análise global dos valores do IEP (T1-T4) não mostrou mudança significativa, mas a comparação de apenas T1 e T2 resultou em redução estatisticamente significativa do IEP. Houve redução significativa do FSC após o posicionado em CP. Conclusão: O posicionado em CP foi associado à diminuição do FSC e dos valores do IEP. O IEP foi afetado pela mudança gravitacional do FSC; no entanto, ambos os fatores não estavam diretamente correlacionados. Além disso, a diminuição do valor do IEP foi transitória e voltou aos valores normais dentro de 20 minutos.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

[Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position]. / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.